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APPLICATION FOR-PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA., PERMIT NO. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED DATE ISSUED �{ <br /> (Complete in Triplicate) 1 <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 /> 1 <br /> Job Address_ A WV_46cy4,rY'Subdivision Name • <br /> Owner's Name ,L v kr b <br /> �- U Address $-Aoft". Phone <br /> Contractor's Name — ftNT/�e •f aN License No, 57 Phone <br /> 1 <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR _OTHER EJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI5p05AL FLD. PROP. LI:NEw <br /> FOUNDATION AGRICULTURE WELL OTHERtWELL. PITS/SUMPS <br /> INTENDED4USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑Manteca Dia.—of'We11'Ezcevativn �f <br /> U Domestic/Private <br /> .,, []Gravel- Pack 0 Tracy Dia, of Well Casing � <br /> Public Other 0Delta <br /> ^ <br /> [=jirrigation Type of Casing <br /> Approx. 0 Eastern <br /> Cathodic Protection Depth Specifications ' ) <br /> Geophysical Depth of Grout Seal <br /> Other Type of Grout <br /> "Surface-Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage p.it permitted if public sewer is <br /> ,Installation will serve: Residence / Commercial Othei available within 200 feet.) <br /> Number of living units. Number of;bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth 30 ' <br /> SEPTIC TANK Ej Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. (]`, Type/Mfg Capacity Metod of Disposal <br /> SEWAGE SYSTEM Distance'to nearest: Well Foundation Property Line <br /> DESTRUCTION. ❑ I_J-, <br /> LEACHING LINEe <br /> &No. Ln th of lines <br /> �-� 9 Total length/size <br /> FILTER BED ] Distance oto.nearest: Well /Qfl 1 Foundation /19 Property tine .2 Or <br /> r <br /> SEEPAGE--PITS E], -Depth Size Number ! <br /> SUMPS L1 Distance to nearest: Well Foundation_. _.... Property Line <br /> DISPOSAL PONDS r <br /> I hereby certify that"I have prepared'ths 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._�I_. " <br /> Home owner or licensed agent's signature certifies the following: "ITcerti`fy 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§ 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 appTi cant mu.t call for all required inspections. Complete drawingon,.reverse side. <br /> Signed X G Title: " r F rDate: s <br /> OR MET <br /> USE ONLY _ <br /> Application Accep b i Area= � Stk. 466-6781 ) <br /> Additional Comments: ®� y0 iodi 369-3621 <br /> Pit or Grout Inspection b Date Manteca 823-7104 <br /> Final Inspection by Date f 7_ L Tracy 835-6385 <br /> Applicant - Return all copies to; Environmen al 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 <br /> 14-26 10/82 500 <br />