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Ale <br /> APPLICATION FOR PERMIT <br /> M <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT 1 �� <br /> 1601 E. WELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> on ereby o the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> escribed. This cation is made incompliance 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 ; Subd+ivision Name <br /> Dwner`s Name 9 <br /> Address c� 0 S N Phone P-swY <br /> Contractor's Name lc Jft License No. G$2.-7&�_ <br /> TYPE OF WELL/PUMP WORK: NEW WELL . WELL REPLACEMENT DESTRUCTIOpI❑ <br /> PMP INSTALLATION L] SYSTtWitEPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISppSAL fLD. �PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR LEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial 0 open Bottom nteca Dia. of Well Excavation f++ <br /> stir/Private ravel Pack Tracy Dia. of Well Casing <br /> Public ether []Be]ta Type of Casing I AP <br /> Irrigation Approx. ❑Eastern SpecificationsfF 17 <br /> Cathodic Protection Depth <br /> 0 _ Depth of Grout 5ea1 <br /> 0 Geophysical Type of Grout if An" <br /> ❑'Other ' Surface Seal Installed by /7 wtt � <br /> Repair Work Done [3 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter. Sealing Material (top 509 _ <br /> Depth Filler Material. (Below 50'.) ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION' (No septic tank or "seepage pit permitted if.public sewer is <br /> U lJ available,withift$00 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 <br /> SEPTIC TANK. ❑ Type/Mfg ..Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING,LINE ❑ No. 9 Length of lines Total.length/size - <br /> FILTER BED ❑ .'Distance to nearest: Nell Foundation Property Line <br /> SEEPAGE PITS, ❑ Depth Size Number <br /> SL94pS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> Mane 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 workmans 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 iWed, I shall apploy persons subject to workman's compensation taws of California." <br /> The appli must ca for required inspections. Complete drawi on rev rse side. ,,, <br /> Signed Title: <br /> Date: <br /> NT USE ONty�, ` , d� Stk 4bb-6781 <br /> Application Accepted byArea <br /> " <br /> Additional Comments: [] Lodi 369-3621- <br /> Pit <br /> 69 3621Pit or Grout Inspection, by Date Manteca 823-7104 <br /> Final Inspection by Date ❑ 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 BASF AMOUNT DUE AMQINiT REliITTED RECEIVED BY DATE PERMIT N0. <br /> INFO Lit <br /> 143.00 � N,�y_ �s� 1�tD <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />