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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT ¢ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � 1 2— <br /> Telephone <br /> Telephone (209) 466-6781 <br /> DATE IssueD 0 (?-g3 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 andRegulationsf the San Joaquio Local Health District. ! <br /> Job Address [ // $ <br /> I if Subdivision Name <br /> Owner's Name' k1l �CA:) d7 fa/ Address p Phone � � <br /> Contractor's Name icense No. p - Phone <br /> r pI1"` <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION'U <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL s— OTHER WELL., ^>`+� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION�SPECIFICATIONS' f <br /> } # <br /> Industrial U:Open Bottom Manteca t Dia. of Well Excavation <br /> Domestic/Private 71,Gravel Pack Tracy } Dia. of Well Casing <br /> o Public C1 Other []Delta Type of Casing <br /> Lj Irrigation I Arox. <br /> ❑ Eastern Specifications <br /> Cathodic Protection Depth of Grout Seal <br /> 17 Geophysical Type of Grout <br /> } U other �. Surface Seal Installed by �. <br /> Repair Work Done Type of 'Pump �r a eL b H.P. State Work Done <br /> } F 4 f <br /> Well Destruction U Well Diameter Pi-- Sealing Material (top 50') <br /> Depth Filler Material (Below 50') r R <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> 'r <br /> Number of living units: . 41 Number of bedrooms Lot size <br /> Character of sail to a depth`of 3 feet: Water table depth <br /> F <br /> i SEPTIC TANK Type/Mfg .j^:. Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity <br /> SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line m <br /> DESTRUCTION <br /> LEACHING LINE f_1 No. Length of lines Total length/size <br /> Y <br /> ' FILTER BED Distance-to_nearest: Well E Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS LJ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C1 � <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county `ate <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 ork for which this <br /> that in the performance of the w <br /> + <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmanS compensation laws of California." <br /> Contractor"s hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applic n must cal ifor ll pu' d inspections. Complete awing o reverse side. - <br /> Signed X Title: /� �__ — Date: <br /> F f�D TM E�USEONLY - ��(� w I <br /> Application Accepted by Area A_ Stk 466-6781 <br /> Lodi 369-3621 <br /> Additional Comments: [� <br /> Pit or Grout Inspection `by Date Manteca 823-7104 <br /> Final Inspection by 7 Date ,7- -FE? ❑ 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 /> FFEEBASE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT�N`O.gf���� 6 3 - FTc L <br /> EH 13-24 REV. 10/82 elke�� �j/ 1 10/B2 500 <br />