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APPLICATION FOR PERMIT � <br /> SAF; JOAQUiN LOCAL,NEALIH'D STRICT Q � <br /> t 1601 E. HAZELTON AVE.:, STOCKTON, CA PERMIT NO. <br /> Telephone (209} 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � <br /> (Complete in Triplica-ce) <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 .3 ZZO Al',- E' A 7— Subdivision Name � <br /> Owner's Name Alli/ N1040"ss Address S _ Phone <br /> Contractor's Name Shy_,,,u icenseI� T� . f Phone CIA i <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER �� 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE '( <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom F� Manteca Dia. of Well Excavation <br /> U Domestic/Private ❑ Gravel Pack Tracy Dia, of Well Casing <br /> 17 Public F-1 Other Delta <br /> Type of Casing <br /> V Irrigation - Approx. Eastern <br /> ❑ Cathodic Protection <br /> Depth Specifications � <br /> Depth of Grout Seal <br /> Geophysical <br /> Type of Grout <br /> Other Surface Seal Installed by <br /> Repair Work Done G Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter + Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> } <br /> ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is A <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of-living' units:`"°"� Number�of bedroom`s Lot site �_ 1 <br /> Character of sail to a depth of 3 feet: R <br /> � Water table depth � p <br /> SEPTIC TANK Ej Type/Mfg - "'""" Capacity No. Compartments <br /> PKG. TREATMENT PLTi Type/Mfg `Capacity Method of Disposal <br /> SEWRGE,SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ __ ___ _ <br /> LEACHING LINE { No. & Length of iines JC .f Total length/size Ar <br /> —'—FILTER-BED- Distance to nearest: Well Foundation Property-Line <br /> S{-EPAG€�iT5 Depth �y �' Size 1p Number <br /> SUMPS Distance to nearest: Well CK, Foundation fa > Property Line l(�' <br /> DISPOSAL PONDS ` <br /> ] 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 cf-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,`1'sh'a1T ilot'"employ'any"person'"iii"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 Califorrii'a.`­ <br /> ^^ <br /> .The_applicant us r all re red'' pections. Complete drawingonreverse side �" s <br /> gned>i' Title: Date: <br /> q c4 I <br /> `H_J FOR DEP ENT USE ONLY ` I <br /> Application Accepted by / [ G Area 6 0-I'tk 466-6781 <br /> Additional Comments: [} Lodi 369-3621 <br /> Pit or Grout Inspection by Date �� �3 Manteca 823-7104 <br /> Final Inspection by Date J 3 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 16011E. 4azelton Ave., P.O. Box 2009, Stk,, CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT fNO. <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />