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APPLICATION FOR PERMIT <br /> \ SAN JOAQUIN LOCAL HEALTH DISTRICT 13- U V <br /> �\ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Q V <br /> Telephone (209) 466-6781 DATE ISSUED o21 a Z-�3 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) co <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein (JJ <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. (.1J <br /> Job Address 4430 S. A4t57-1✓ 4D Subdivision Name <br /> Owner's Name '-VUAA E ".4P-77AI Address 4WE?iePhone <br /> Contractor's Name -EL42Y.0 6. JV Veo License No. 47,C;1-76 Phone 4!k3!FW <br /> TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 /> ❑ Industrial U Open Bottom ❑z Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing <br /> ❑ Public ❑Other ❑ Delta Type of Casing <br /> Irrigation Approx. ❑ Eastern Specifications <br /> Cathodic Protection Depth <br /> F-1CathodicDepth of Grout Seal --' <br /> ❑Geophysical Type of Grout <br /> ❑Other Surface Seal Installed by <br /> Repair Work Done [J Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/.ADDITION [e 01(Noseptic tank or seepage pit permitted if public sewer is LJ <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: 5.4 No y Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments (�- <br /> PKG. TREATMENT PLT. ❑ Type/Mfg OXI Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines /—lee Total length/size ) - <br /> FILTER BED ❑ Distance to nearest: Well Foundation aoO I Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 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 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 call for all required inspectio Complete drawing on reverse side. <br /> Signed X �'�Ir_— ,� Title: ' Date: �Z�L]��� <br /> ENT U LY <br /> Application Accepted i Fie // _Area ❑ Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date .ti�'2, 3 ❑ Tracy 835-6385 <br /> Applicant - Return all copiea o: 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 p �PERMITINFO 1 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />