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APPL-CAT[ON FG? PEKM-T <br /> f <br /> • �` S=N JOA�Li`r LOCA_ NEA LTH ;:STRICT p <br /> 1601 L. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209; 466-6781 - <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 74 &,MP'C"-1- el Subdivision Name <br /> Owner's Name M� Address <br /> Phonei�� +� � <br /> Contractor's Name License No. 4 Phone <br /> i <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION FI SYSTEM REPAIRl <br /> I❑ OTHER I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER 14ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack IW; Tracy Dia, of Well Casing <br /> Public Other U Delta Type of Casing <br /> L) IrrigationApprox, ❑ Eastern <br /> Specifications <br /> Cathodic Protection Depth <br /> Geophysical <br /> Depth of Grout Seal <br /> LJ Other <br /> Type of Grout <br /> Surface Seal Installed by ! <br /> Repair Work Done ❑ Type of Pump N.P. _ State Work Done --_1 <br /> Well Destruction 0 Well Diameter Sealing Material (top 50') <br /> w <br /> Depth Filler Material (Below 50') / <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION f< (No septic tank or seepage pit permitted if public sewer is <br />- Installation will serve: Residence 0(-. Comavailable within 200 feet.) <br /> mercial Other <br /> Number of living units: I__. Number of bedrooms �— Lot size 725">(/7- -.�> <br />. Character of soil to a depth of 3 feet: bJater table depth {��} <br /> SEPTIC TANK LJ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal -� <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ - �_ <br /> LEACHING LINE No. & Length of lines / r *ep,F Total length/size ;>( Ljf,TA <br /> FILTER BED Distance to nearest: Well Ar� Foundation -52Property Line S X <br /> SEEPAGE PITS Depth /d Size IV X 8' Number / <br /> SUMPS Distance to nearest: Well 0 Foundation � Property Line <br /> A-77 ' <br /> DISPOSAL PONDS F—I <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 iH ng or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit issued, I shall employ persons s jest to workman's compensation laws of California." <br /> The applic st call f all r d ions. Complete o reverse side. <br /> Signed 12- Title: _ _ L [l.��f'L �fj Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Area Nrlstk 466-6781 <br /> Additional Comments: U Lodi 369-3621 <br /> Pit or Grout Inspection by Date U Manteca 823-7104 <br /> Final Inspection by Date f — / L Tracy 835-6385 <br /> Applicant - Return all copies to: iv vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASL AMOUNT DUE AMOUNT REMITTED RECEIVED BY T DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REG'. 10182 10182 500j <br /> 14-26 �'0 <br />