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APPLICATION FOR PERX!T <br /> SAN JOAQUiI,' LOCAL H;tALTH DISTRICT <br /> 1601 E, HAZELTON AVE., ST0,CKTON, CA PERMIT NO. - �I S3 <br /> Telephone (209) 466-6.781 <br /> PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED DATE ISSUED p -1_1-�3 <br /> (Complete in triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No, 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. 1 y <br /> Job AddressL= Subdivision Name <br /> Owner's Name sSMWPhone `?— <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL -WELL,.REPLACEMENT [� DESTRUCTION ❑ (d <br /> - PUMP INSTALLATION SYSTEM REPAIR -OTHER-U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r <br /> FOUNDATION,... AGRICULTURE•WELL, J >< OTHER 1d ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL �r PROBLEM AREA ! CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca-" Dia, of Well Excavation <br /> U <br /> Domestic/Private E]Gravel Pack � Tracy, f.'J ,' 6 Dia. of Well Casing <br /> l� Public �J Other D Delta 4 <br /> { " �- Type of Casing <br /> V' Irrigation Approx, Eastern <br /> f—ISpecifications <br /> Cathodic Protection Depth S P <br /> Geophysical <br /> Depth of Grout Seal <br /> Other Type of Grout <br /> Surface Seal Installed by <br /> Repdir Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/,ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Instal. ,#jsr�..wi^$ serae-4�Residence. .nr6orftFrc al _ Other <br /> Number of living units: - Humber of bedroomsLot size <br /> T� 4E; <br /> Character of sail to a depth of 3 feet: _ Water table depth <br /> SEPTIC TANK Type/Mfg C9P,(& { Capacity ��� No, Compartments _7 <br /> PKG, TREATMENT PLT, Type/Mfg Capacity Method of,Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: We 11 1 t Foundation Z I Property Line 7-,a <br /> SEEPAGE PITS Depth Size.. l tdf Number 3 <br /> SUMPS ., Distance to nearest: Well Foundation �._— Property Line /1! JF <br /> DISPOSAL <br /> AL` PONDS <br /> I hereby certify that I have prepared this application and that the work will be done in 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 that in the performance of,the work for which this t '� <br /> permit is issued, I shall not employ any person in such manner as-to become subject to workmant compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the ft-Tlaw`ing: `I certify ttat in the performance of the work for'which• <br /> this permit is ssued, I shall employ per ons subject to workman's compensation laws of California." <br /> The applic call for 11 requirqVinsctions. Compl Ae dra ' on reverse side. <br /> Signed X O'itle:,.. Date:, <br /> FO A ENl USE ONLY <br /> Application Accepted by Area �Stk 466-6781 <br /> Additional Comments: C] Lodi 369-3621 <br /> Pit or Grout Inspection by Date LEI Manteca 823-7104 <br /> Final Inspection by Date ID/� ff3 ❑ Tracy' 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />