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APPLICATION FOR PERmTT <br /> SAN jWb iN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1.YEAR FROM DATE ISSUED 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 and Regulations of Ue SanJcac ocal Heal h District, <br /> t 12Job Address �`I AVOOS409 Name <br /> Owner's Name Address <br /> Phone <br /> Contractor's Name `7"1Z,�L (!fi'egnse No �[[j Z Phone�� —TQC <br /> i <br /> TYPE OF WELL/PUMP WORK: NEW WELL �] WELL REPLACEMENT_J[] DESTRUCTION <br /> ...�" <br /> PUMP INSTALLATION SYSTEM,REPAIR- U. � <br /> DISTANCE TO NEAREST: SEPTIC TANK _�Q-7g) SEWER LINES <br /> -1 (» DISPOSAL FLD. - PROP. LINE <br /> FOUNDATION AGRICULTURE WELL;..fes OTHER'"WELL"fk _1 PITS/SUMPS <br /> INTENDED USE, � ..p._-.,�.�EL E _C <br /> r <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w � <br /> el Irtduetrlal _ Open Bottom Manteca Dia. of Well Excavation <br /> r Domestic./Private Gravel Pack Tracy Dia, of Well Casing <br /> :�KPubIIl'c+ EOther Delta <br /> Irrigation Type of Casing <br /> .­ , Approx. [� Eastern" 1 <br /> j CdthOd`iC Protection Depth Specifications <br /> ! Geophy�ca Depth of Grout Seal <br /> I ❑ether Type of Grout <br /> I iSurface Seal Installejd by <br /> + ; Repair Work Done Type of Pur �7- 4; <br /> f State Work Dane <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) r <br /> Depth Filler Material (Below 501) <br /> TYPE OFjSEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION C (No septic tank or seepage pit permitted if public sewer is <br /> F <br /> ` lnstailation will serve: Residence _ Commercial � Other available within 200 feet.) <br /> i Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of.3 feet: Water table depth <br /> S SEPTIC TANK'S <br /> � Cj Type/Mfg Capacity No. Compartments <br /> PKG: TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> i✓ ;DESTRUCTION ❑ <br /> LEACHING LINE ❑ No. & Length of lines "Total length/size <br /> BED BED Distance to nearest: Well Foundation Property Line <br /> ',',,,SEEPAGE PITS <br /> ❑ Depth <br /> Size Number <br /> kt SUMPS Lwl Distance to nearest: Well ( ,1 Foundation Property Line c <br /> F 'DISPOSAL PONDS D ' <br /> e rI 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' an 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 i <br /> permit)is issued, I shall not employ any person insuchimanner.,.as to became subjectoto workman compensation laws of California." <br /> E-"Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> k,�this perm, is issued, I shall em ljd;i, so ubject to workman's mpensation laws"of California." <br /> 3 <br /> ` The appl " an ust cal f r a 1 , ° :'s <br /> qn p tions, Camp w ng on re verse side. <br /> Signed : I T-it7. .- Dater <br /> ENT S LY <br /> P .~ � <br /> Application-Accepted"- <br /> P � - � - Area � � Stk 466-6781 <br /> Addi.t,ional Comments-, <br /> v #�yar" ,114 �p�` Lodi 369-3621 <br /> Pit"or GroutxI"nspecti$ni y L Date LJ Manteca 823-7104 <br /> gFinal Ins"pection 6y '"' Date Tracy 835-6385 F <br /> Applicant - Return all copie t ironmental Health Permit/Services 160 E. zel on Ave., P.O. Box 2009, Stk., CA 95201 ' <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 5 , <br /> �z S-71 E-7-1-LS <br /> EH 1324 REV, 10/82 10/82 500 <br /> % 14;26 <br /> ter.-_ <br />