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APPLICATION FOR PERMIT <br /> ttti jJ <br /> S SAN JOAQUIN LOCAL HEALTH DISTRICT —7 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED 7 � <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 ((ayynn�d Re u1ALipns of the San Joaquin Local Health District. ,/ <br /> Job Address &9, &, f� ! i Subdivision Name 04K/Cre-a C UA�1ITI*.� <br /> Owner's Name 0=4t 6 eVC Address M _ Phone <br /> Contractor's Name 6 Rx ajp:r [o, Licen No. 27/ T7:A PhoneAVY <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION L (� <br /> PUMP INSTALLATION - SYSTEM REPAIR L OTHER U r 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK A)� � SEWER LINES DISPOSAL FLD/( PROP. LINE <br /> FOUNDATION —7_` -- AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INT DED USE TYPE OF LL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L I ustrial <br /> E] Op ottom Manteca Dia. of Well Excavation <br /> _ Domestic/Private ravel Pack Tracy Dia, of Well Casing <br /> Public L Other E] Delta Type of Casing — <br /> Lj Irrigation Approx. Eastern <br /> L Cathodic Protection Depth Specifications <br /> 17 Depth of Grout Seal <br /> Geophysical <br /> U Other Type of Grout <br /> 1 Surface Seal Installed by <br /> Repair Work Done [J Type of Pump (� H.P. ` State Work Done _ �` L <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION L (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth rn <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments , <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM o Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE L No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Lj Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C� <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 a ent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued, I sh 1 t employ any person in such manner as to become subject to workman compensation laws of California." <br /> Contractor's hiring or b-c r ting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued m loy ersons subject to workman's compensation laws of California." <br /> The applic u c 1 a q ed 'nspections. Complete0��ky( <br /> �_ <br /> Signed XTitle: Date: <br /> FOK DE TMENT USE ONLY t <br /> Application Accepted by 1 Area �t Stk 466-6781 <br /> Additional Comments: V Lodi 369-3621 ��# <br /> Pit or Grout Inspection by Date ? Z7 cr3 Manteca 823-7104 <br /> Final Inspection by Date a L Tracy 835-6385 <br /> Applicant - Return all copies o: E ironmenta Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> �3 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />