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( No septic tank or seepage pit permitted if public. sewer is <br />available within ROO feet.) <br />TYPE OF SEPTIC WORK: NEW INSTALLATION Li REPAIR/ADDITION — <br />e, <br />SEPTIC TANK <br />P. TREATMENT PET. <br />SEWAGE SYSTFm <br />DESTRUCTION <br />LEACHING LIN <br />FILTER <br />SEEPAGE PITS <br />SUMPS <br />DISPOSAL PONDS <br />Installation will serve: Residence <br />Number of living units: <br /> <br /> Number o <br />Character of soil to a depth of 3 faei2t:it„, <br />TYPe/Mf9 <br />Type/Mfg <br />Distance to nearest: 0 <br />142,— <br />Li <br />El <br />No. a Length of linesop4 <br />Well ,Oz, / 'Foundation e to nearest: ' sProperty <br />line <br />— Size _ 3;;r74-- . Number i <br />,.--' Depth .1. / <br />Distance to nearest: Well/SW Foundation AO Property Line <br />Comrercial 0 <br />Foundation / 4,' <br />Lot size <br />,Water table depth <br />Capacity .:14o. Compartments <br />apacity Method of Disodsial <br />Prop'e'rty Line 3— <br />Total Irgth/size <br />6- <br />T <br />1 hereby certify that I have prepared this application and that the work will be donein accordance with San Joaquin county <br />ordinances. state laws, and rules and regulations of the San Joaquin Local Health District.' <br />Home owner or licensed agent's signature certifies the following: 'I certify tbat in the'performace of the work for which this <br />permit is issued, I shall not employ any person in such manner ,as.to .become subject to workmant compensation laws of California." <br />i-...”----Contractorts hiring or-sub-contracting signature certifies the following: "I certify ihat ih -the performance of the work for which_ <br />this permit is issued, I shall employ persons subject to workman's compensation laws -of -C-a-ITfarnia," <br />10/82 SOO EH 13-24 REV. 10/B2 <br />14-26 <br />The applmust c I required inspeetcons. -Complete drAing o <br />Signed X Title:.- <br />FOPEpARTMENTIISE ONLY <br /> <br />Additional Comments: <br />Pit or Grout Inspection <br />Final Inspection by <br /> <br />Return.all copi nvi onuienI2l Heal <br /> <br />O 5th 466-6781 <br /> <br />Lodi 369-3621 <br />Mariteca 823-7104 <br />O Tracy 835-6385 <br />e ton Ave., P.O. Box 2009, Stk., CA 95201 <br />_ _ <br />Appl ulon-ACtepted by <br />Date <br />Date <br />ermit/Services 1101 . _ <br />AMOUNT DUE J AMOUNT REMITTED <br />2-1 <br />RECEIVED -BY DATE j PERMIT NO. <br />lc) <br />FEE RASE <br />INFO <br />„ <br />ARKICATION FOR PERMIT <br />SAN JOAQUA LOCAL. HEALTH pISTRICT <br />1601 E. HAZELION AVE., STOCKTON, CA <br />' Telephone (209) 466-6781 <br />PERMIT NO. --I tog <br />DATE ISSUFU <br />PER <br /> <br />1RES I YEAR ROY DATE ISSUED <br />Comolete in Tripl icate) <br />Application is hereby made to the Sar Joaquin Local Health District for a permit to construct and/or insta11 the work hereir <br />de in compliance with Sar Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br />'it San Jgegiiin 1,dcal Health District, <br />Ej Ire/. 64441'11 beivision Name <br />7 r7p <br />_321(22-fiz: <br />describeo. This application <br />and the Rules and 1 tio <br />Jot Address 27-7 <br />Owner's Nam <br />Contractor's <br /> <br />Address 111011 4f, <br />.4,114.4.4 1;rff <br />'1 <br />License <br /> <br />Rhone <br /> <br />TYPE OF WELL/PUMP WORK: NEW WELL <br />PjMP INSTALLATION <br />DISTANCE TO NEAREST: SEPTIC TANK <br />FOUNDATION <br />INTENDED USE <br />TYPE OF WELL <br />13 Industrial <br />Open Bottom <br />Li Domestic/Private <br />E Gravel Pack <br />" Public Other <br /> <br />1_,J Irrigation Approx. <br />Cathodic Protection <br /> Depth <br />0 Geophysical <br />DOther <br />Repair Work Done 0 Type Of Pump <br />Well Destruction 1.1 .Well Diameter <br />Depth <br /> AGRICULTURE WEL <br />PROBLEM AREA <br />1:2 Manteca <br />Tracy <br />71 Delta <br />fl EaStern <br />CONSTRUCT:0N SPECIFICATIONS <br />Die. of Well Excavation <br />Dia. of Wel" Casing _ <br />Type of Casing <br />Specifications <br />Deptn of Grout Seal <br />Type of Grout <br />Surface Seal. Insia-1 fia by'* <br />State Work Done <br />Sealing Material (top 50 ') <br />Filler Material (Below 50') - - <br />WELL REPLACEMENT <br />D SYSTEM REPAIR <br />Li <br />SEWER LINES <br />DESTRUCTION fl <br />OTHER Li <br />DISPOSAL FLD. <br />OTHER WELL <br /> <br />PROP. LINE <br />PITS/SUMPS <br />