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SEEPAGE PITS C./Depth ,5 Size 3.Z Number
<br />I SUMPS 0 Distance to nearest: Well 1.t,CD Foundation t1 0 ' Property Line q
<br />1 (DISPOSAL PONDS 0
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<br />- ir.-- APPReATION FOR-PERMIT,.. - ..,t,y;:
<br />SAN JOAQUIN LOCACHEALTH DISTRICT:, ,
<br />1601 E. HAZELTOW'AVE., StOCKTON, CA
<br />Telepticine.(209) 466-6781
<br />PERMIT EXPIRES l'YEAR FROM DATE ISSUED° tt 'ca ...-
<br />(Complete in Triplicate)' ''' ' ''-'3 *Y" t t
<br />u• . • 6. ••••• st!.(1 • .7. , ! . 1- . .,.
<br />Application is hereby made to the Sari Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is i made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin
<br />Local Health District. ' - 46' • : ' ;•1: '
<br />Job Acidress • / • -"ligic:;650
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<br /> Phone
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<br />......--.-..-..-INTENDED.USE..........--.T.YPE.OF-WELL----:--PROBLEM-AREA----CONSTRUG-TION-SPECIFIC-ATIONS ...........•
<br />ILI Industrial . 0 13 ], iien Bottom 4:•••4
<br />- CI Tracy
<br />D Manteca Die, of Well Excavation " l
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<br />Dia. of Well Casing
<br />0 Domestic/Private 0 Gravel Pack Specifications Type of Casinij .._
<br />1 - ..; El Otheril • 0 Public 0 Delta Depth of Grout Seal - i Type of Grout
<br />i. 1.0 Irrigation . ..Approx. Depth 0 Eastern Surface Seal Installed by I
<br />sRepair Work Done LI Type of -Pump ' t I.P. , L.7•• .- - State yVork Deno
<br />1,14/ell Destruction 0 Well Diameter ' Sealing Material (top 501 - 4 ..:'''
<br />I Depth It Filler Material (Below 50')
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<br />'TYPE OF SEPTIC WORK: NEW INSTALLATION El"'AIR/ADDITION 0 .DESTRUCTION 0 (No septic system permitted if public sewer is 1
<br />L„.......--- 1 available within 200 feet.) . •• -*.t., r•-•-•
<br />Installation will serve: Residence Commercial ____ Other I . i
<br />4' Numhlir of living units. ..... Number of beiirooms"----3'"7" i
<br />, Character of soil to a depth of 3,feet'l C L. c.v./ . ',.. 1 .'• - i Water table depth
<br />SEPTle,4ANK Lt,Type/Mfg "1..-.0 It....1k C-YrV...,ikt.. Capacity I .).DC) NI Compartments ____1'...t.:.„, '•
<br />L. 1,1
<br />'PKG. TREATMENT PLT. 0 • r'''3 _....;. I Of 1 Method of Disposal
<br />Distance to nearest:,s4 ,Well1()(11 Foundation ' -1/ 0 Property .Line 7 5 , . 2...- .• .. ..1 I
<br />, LEACHINGIllislE't " .' ....L'L .to."--8 tIngitt o'f lines' :...--:-----4 .)- • -4. ''''.' '' ' .Toiel lerrigthisize -I- 1'1 C)
<br />!FILTER BED El Distance to nearest: Well je) '.- Foundation Property, Line 73
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<br />, I hereby certify that I have prepared this applicatior) and that the Wbrk:will be done in accordance with San Joaquin county ordinances, stele laws, and
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<br />: Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not
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<br />. employ any person in such manner as to become subject to Workman's, compensation laws of California." Co'ntractor's hiring or sub-contracting signature
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<br />certifies the following: "I certify that in the performance bf the work for Which this permit is issued, I shall emilloy persons subject to workmen's compensa-
<br />tion la of California." \ $ t
<br />.P: . on reverse aid
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<br />The applic. .i..._ust call for all req ied in ctio ig pie drawing i
<br />it Tarl .....M._._ A 1 Me:
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<br />I -0 FOR DEPARTMENT USE ONLY
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<br />S-C-Final Iri4;ection by
<br />. CI 8th 466-6781 0 Lodi 369-3621 0 Manteca 023-7104
<br />I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201
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<br />Contractor Lz-r, vki V-M....ttkoiltt_i.. Address 3 t-.....1 $ License .fio:3-5 )411.. Phone 9 R D.SAA4 - -TYPE-OF-WEll:/PUMP: - - - NEW-WELL 0 WELL-REPLA'CEMEN1'0 — -----:DESTRUCTION-0" -*" -- — — - - ' i
<br />PUMP INSTALLATION 0 SYSTEM REPAIR 0 • OTHER 0
<br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE
<br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS
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<br />Owner i t''
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<br />Address..
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<br /> "Lot S'ii; 'D• X3StIpm
<br />. rules and regulations of the San Joaquin Local Health District. *...,••
<br />Application Accepted by
<br />I Pit or Grout Inspection by
<br />I Additional Comments. '
<br />Date: 7 -3 /
<br />Area z
<br />Date? -
<br />El Tracy 835-6385
<br />+ (H 15-24 I REV. l ies)
<br />EH 14-28
<br />FEE
<br />INFO
<br />7. .„,x.. :
<br />1 AIVIOU0 DUE AMOUNT REMITTED 1 c•rP RECEIVED BY : DATE PERMIT'NO. •
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<br />/••:•1 , : 1M..c...,...:i •• to.77..Tr.--... Q ...,:;\---7—,..i..... ..:'-..7.((- .e.5:--,,..--•,s-
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