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APPLICATION FOR PERM17 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED r <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address Al ,Al-&& -Subdivision Name <br /> Phone <br /> Owner's Name ±A"S pL1���F�� / Address r Phone 3 g7� <br /> Contractor's Name �(�p✓D ��1Qs2.?]-- License No, <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT F� - DESTRUCTION ❑ <br /> PUMP INSTALLATION �] SYSTEM REPAIR OTHER U <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 17Industrial 17Open Bottom Manteca <br /> Dia. of Well Excavation � <br /> LJ Domestic/Private E]Gravel Pack Tracy Dia. of Well Casing <br /> Public [—I Other [] Delta Type of Casing <br /> Lj Irrigation Approx. E] Eastern Specifications <br /> ❑Cathodic Protection Depth Depth of Grout Seal <br /> i <br /> ❑Geophysical Type of Grout <br /> U Other Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H p State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ). (No septic tank or seepage pit <br /> availableewithind if u200cfeet.) is <br /> Installation will serve: Residence 011" Commercial _ Other <br /> Number of living units: I Number of bedrooms _ _ Lot size <br /> 6 <br /> Water table depth <br /> Character of soil to a depth of 3 feet: �a�/�'tf No. Compartments °jam <br /> SEPTIC TANK [V Type/Mfg Capacity TL1[�f� <br /> Capacity Method of Disposal <br /> F-1PKG. TREATMENT PLT. � Type/Mfg Property Line <br /> SEWAGE SYSTEM Distance to nearest: Well O_ Foundation �Q - <br /> DESTRUCTION <br /> of lines ° •,Total length/size ''7^ "yZ � <br /> LEACHING LINE �/ - No. & Length "' <br /> FILTER BED Distance to nearest: Well <br /> Foundation` Property Line <br /> _ <br /> SEEPAGE PITS Depth ' <br /> _ ;,j, .-.9 Size °' Number � <br /> �— Foundation ;Cop° Property Line LS <br /> SUMPS �� Distance to nearest: Well �..04� <br /> DISPOSAL PONDS <br /> I hereby certify that 1 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 cersoniin suchfmannernas to becomeysubjectthat ntohworrkman� compensate performance of ionwlaws fof California." <br /> permit is issued, I shall not employ any p <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for whit <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." �1 <br /> The applicant must c 11 for all required insp tions. Complete draw on reverse side. Date: <br /> (A <br /> Signed X Title: <br /> FOR DEPARTMENT USE ONLY Area Pi& Stk 466-6781 <br /> Application Accepted by V <br /> 0 Lodi 369-3621 <br /> Additional Comments: Date Manteca 823-7104 <br /> -� <br /> Pit or Grout Inspection by <br /> Date Tracy 835-6385 <br /> Final Inspection by <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Av4., P.O. Box 2009, St k., CA 952-01 <br /> RECEIVED BY DATE PERMIT N0. <br /> [FEE BASE AMO��UEAMOUNT REQITTED �jO �S G 1 1�� %�`.� 1 5 �- 403� <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />