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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781 iM <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �Y.s72{ yC (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 <br /> Job Address vision N'1&r (4,0-0/ <br /> Owner's Namej��� ss - Phoria <br /> Contractor's Name L cense No. Phone �.r1_-7" Cr <br /> TYPE OF WELL PUMP WORK: NEW WELL '" WELL REPLACEMENT DESTRUCTION <br /> a- PUMP INSTALLATION SYSTEM REPAIR OTHER [] <br /> DISTANCE TO NEAREST: SEPTIC TANKE ,L-INES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE LL <br /> OTHER WELL PITS/SI1MP5 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA Ire <br /> CONSTRUCTION SPECIFiCATI0N8 ff <br /> Q Open Bottom []Manteca Dia. of Well Excavation E I. <br /> Domestic/Privateravei Pack 'Tracy Dia. of Well Casing IM <br /> J-1 Publ is F1 Other (]Delta II li <br /> Type g ��� p � I l <br /> Lj Irrigation. Approx. Eastern pe of Cason cs+' <br /> ❑Cathodic Protection Depth Specifications I� <br /> 1-1 GeophysicalDepth of Grout Seal S rr/ <br /> . - y 3 A <br /> Type of Grout _ IM <br /> Other Surface Seal Installed by . I� <br /> Repair Work Done (] Type of Pump H.P. State Work Done <br /> Well Destruction well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50;1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L_ REPAIR/ADDITION fJ (No septic tank or seepage pit permitted if`'pubiic sewer is I' <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial Other <br /> Number,of living units: Number of bedrooms Lot size <br /> Character of soil to a de <br /> th of 3 feet: si <br /> P � Water table depth _ <br /> ' SEPTI TANK G 'Type/Mfg Capacity No. Compartments <br /> s PKG. TREATMENT PLT-0. Type/Mfg• , . Capacity Method of Disposali' , �h <br /> b Distance to nearest: Well Foundation Property Line LI <br /> Ap— <br /> LEACHING LINE, EJ_ No, 8 Length of lines Total length/size IM ' <br /> FILTER BED ED '. Distance to nearest: Well Foundation - Property Line I� <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS LJ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br />• ! I <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 <br /> permit is.issued. I shall not employ any person in such manner as to become subject to workman k compensation laws of California." <br /> Contracto'r's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permot'is issued, I shall employ persons subject to workman's compensation laws of California." <br /> l The applitan us ca for required inspections. Complete dra g on r erse sid <br /> AX,7 1"�4_ <br /> Signed X ATitle: Date: . <br /> FOR DEPA.fENT USE ONLY I� <br /> Application Accepted by , X-- „ v., r. Area 0 [] Stk 466-6781 <br /> Additional Comments: no <br /> Q Lodi 369-3521 <br /> Pit or.(Vout*lpspection by Q - Date { w Manteca 823-7104 <br /> Final Inspection by Date h <br /> ,' racy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,11.Stk., CA 95201 <br /> i <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERML� N0. <br /> 1NFO <br /> EH 13-24 REV. 10/82 110/82 500 <br /> 14-26 III <br />