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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 DATE ISSUED LA <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ' <br /> n'Joaquir Local Health District for a permit to construct and/or install.the work herein <br /> Application is hereby made to the Sa <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, S a�� 196) <br /> Q <br /> Job Address y G- V l Q Sl1ubdivision Name !S D 17 V 7 <br /> 1 O a�,Q Address 1 Phone dln� <br /> Owner's -Name /'�Tpi � _ -. Phone <br /> Contractor's Name r+ <br /> License No. Z-3. <br /> s <br /> TYPE OF WELL/PUMP WORK: NEW WELL [ WELL REPLACEMENT [e"' DESTRUCTION U <br /> PUMP INSTALLATION OTHER <br /> SYSTEM REPAIR 0 U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , <br /> i <br /> Dia, of Well Excavation <br /> !J Industria} U Open Bottom Manteca_ <br /> Domestic/Private Gravel Pack Tracy Dia. of Wel}_Casing <br /> y�Public [Other �elta Type of Casing 1 y r G <br /> L`i Irrigation s Approx. Eastern Specifications <br /> Cathodic Protection <br /> Depth Depth of Grout Seal!, 0 <br /> Type of Grout tL.-k- <br /> Geophysical JOS <br /> Other Surface Seal Installed by V1 t <br /> H.p. State Work Done <br /> Repair Work Done ❑ T pe of Pump ^~ a <br /> Well Destruction Well Diameter �_._ Sealing Material (top 501) <br /> DepthS7 Filler Material (Below 50') <br /> sewe <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage piadailableewithin if u?00cfeet.) is <br /> Installation will serve: Residence _ Commercial f Other <br /> Number of bedrooms Lot size <br /> Number of living units: Water table depth <br /> Character of sail to a depth of,3 feet: No, Compartments <br /> SEPTIC TANK F-1 Type/Mfg Capacity <br /> Capacity Method of Disposal <br /> PKG. TREATMENT PLT. Type/Mfg Property Line <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation <br /> DESTRUCTION <br /> U No. & Length of lines Total length/size <br /> LEACHING LINE Property Line <br /> FILTER BED Distance to nearest: Well Foundation <br /> SEEPAGE PITS <br /> De Size Number <br /> [j Depth Property Line <br /> SUMPS �! Distance to nearest: Well Foundation <br /> DISPOSAL PONDS <br /> I he certify that I haver prepared this regulations application and <br /> dathat <br /> aoaquinwork <br /> will <br /> be done <br /> in accordance with San Joaquin county <br /> ordinances, stat ,. <br /> Home owner or, <br /> r lcensed agent signature certifies the following. "I certify that in the performance of the work for which this <br /> permit is i ued, I shall no employ any <br /> Son ch manner as to bncomeIsCecfytthatrknathe cperformance ofensation wthe fwork�for nwhich <br /> Contractor's hiring or sub ontracting natu ect, o workman's ompensation laws of California." <br /> this permi is issued 11 e to <br /> de. <br /> The applica mus r a i s Complete ing on r se si <br /> r <br /> Date: <br /> Title: .� � <br /> Signed X F DEPARTMENT USE ONLY Area—�7 O 9 tk 466-6781 <br /> Application Accepted by ,.FfT Lodi 369-3621 <br /> Additional Comments: Manteca 823-7104 <br /> Date <br /> E] <br /> Pit or Grout Inspectionby <br /> Final Inspection by Tracy 835-6385 <br /> Date 71 L <br /> Applicant - Return all copies to: vironmentP.O. Box 2009, 5t k., CA 95201 <br /> al Health Permit/Services 1601 E. Hazelton Ave., <br /> I EEE BASE AMOUNT DUE AMOUNT REMITTED <br /> RECEIVED BY DATE PERMIT NO. <br /> gg .1; <br /> -,X o 0 <br /> r 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />