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xY <br /> APPLICATSON FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Z <br /> 1661 <br /> E. HAZELTON AVE., STOCKTON, CA JUL ! 81983 <br /> PERMIT NO. <br /> Telephone (209) 466-6781 l! 1 Jv DATE ISSUED, O <br /> PERMIT EXPIRES 1 YEAR •FROM DATE ISSUED � � �C�L <br /> (Complete in Triplicate) SAN HMM DIS-fRICT <br /> Application is hereby made to the San Joaquin Local Health District for a' Qermit 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,Regulati fythe San J quin LDca Health.District. <br /> Job Address Subdivision Name <br /> Phone <br /> Address- ! <br /> Owner's Name r <br /> Contractor's N e <br /> V,6,A,Jkmn,��kicens'e No. Phone � <br /> kem <br /> TYPE OF WELL/PUMP WORK:, NEW WELL'," .Q , ELI: REPLACEMENT � DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE l <br /> —� PITS/SUMPS <br /> FOUNDATION AGRICULTURE"WELL OTHER WELL <br /> INTENDED USE T17E OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ) <br /> Industrial U Open.Bottom Manteca Dia. of Well Excavation <br /> mestic/Private ❑ Gravel Pack [] Tracy,. Dia, of Well Casing <br /> Public F_�Other Delta Type of Casing <br /> LJ Irrigation Approx. E] Eastern Specifications <br /> Cathodic Protection Depth 3 ' <br /> Depth of Grout Seal <br /> 1-1 Geophysical Type of Grout <br />'i ❑Otherq� Surface Seal Installed by <br /> Repair Work Done Type of Pump H•P• State Work Done <br /> Well Destruction F-1Well Diameter Sealing Material (top 50') <br /> Depth + Filler'Material (Below 50') r , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION j .(No septic tank or seepagepit permitted if public sewer is �V, <br /> available within 200 feet.) <br /> t r <br /> Installation will serve: Residence _ Commercial �' Other p <br /> Number of living units: Number of bedrooms Lot size e <br /> Character of soil to a depth of l3 feet: "` <br /> Water table depth <br /> SLPTIC TANK �j Type/Mfg <br /> Capacity No. Compartments <br /> i ? Capacity Method of Disposal ri <br /> PKG. TREATMENT PLT. ❑ Type/Mfg �� � - <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation ` Property Line <br /> DESTRUCTION <br /> No. & Length of lines Total length size <br /> LEACHING LINE jJ 9 <br /> s FILTER BED �. <br /> Distance to nearest: Well Foundation Property Line <br /> F SEEPAGE PITS Depth Size Number <br /> SUMPS LI <br /> Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I 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 San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: ormance of the work for which this <br /> "I certify that in the perf <br /> permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California."i <br /> I 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 law of California." <br /> s side. <br /> The applicant st call f all req ed i ections. mplete dr wing on reverpate: <br /> Sig, itle: <br /> F DEPAR MENT USE ONLY Stk 466-b781 <br /> Application Accepted by Area <br /> (� Lodi 369-3621 <br /> Additional Comments: Manteca 823-7104 <br /> Pit or Grout Inspection by Date <br /> f' Final Inspection by <br /> Date c�z' L7 Tracy 835-6385 <br /> - ' l Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant Return all copies to: Fnvironmerta <br /> T FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE <br /> PERMIT N0. <br /> INFO �s `? - <br /> 7 G <br /> 10182 500 <br /> FH 13-24 REV, 10/82 <br /> 14-26 <br />