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APPLICATION FOR PERMIT <br /> S4'N JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 23- Z0 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED 4-2-2--93 <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 /> OQ <br /> and the Rules and Regulations of the San Joaq ' Lo 1 He lth District. LA <br /> Job Address Q S p i,Subdivision Nam i <br /> Owner's Name Address 902 DS Phone �j'3/ /7C�a? 9 <br /> Contractor's N 2 License No. S S a '-j Phone _-i <br /> TYPE OF WELL/PUMP WORK: NEW WELL J WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER J <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 /> II IIndustrial J Open Bottom J Manteca Dia. of Well Excavation <br /> 2 Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing <br /> L_� Public JJ Other E] Delta <br /> Irrigation Irri Type of Casing <br /> 7, 9 Depth <br /> ❑ Eastern Specifications <br /> J Cathodic Protection <br /> Depth of Grout Seal <br /> 17 Geophysical ..� <br /> J Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done �f Type of Pump r H.P. State Work Done O 0 <br /> Well Destruction J Well Diameter Sealing Material (top 501) v 1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION J REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence Commercial _ Other available within 200 feet.) :57 <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK JJ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. J Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ <br /> LEACHING LINE J No. & Length of lines Total length/size <br /> FILTER BED J Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Jj Depth Size Number <br /> SUMPS J) Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS J <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: "I certify 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 applicant must c 1 for all required inspections. Complete drawing onrev�er a side.07— <br /> p <br /> Signed X Title: c��1i Date: <br /> nnp R DEPARTMENT USE ONLY <br /> Ap ication Accepted by ,�y\ Area Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by �'I/f, n�ire�r.C�� - Date , 3 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental 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 S ,flys n -u-83 g3--2- 7 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />