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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTDN 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 /> Application is hereby made to the San Joaquin Local Heali'h District for a permit to construct and/or install the work herein <br /> described. This application is made it 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 /> ,lob Address 261*141_ ;�_��. - Subdivision Name <br /> Owner's Name Ardd ssP.O. Phone ' - <br /> Contractor's Name nse No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPL CEMENT DESTRUCTION 1 <br /> PUMP INSTALLATIONSYSTEM RE IR F,.il OTHER <br /> Q-� SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK JQ <br /> FOUNDATION -".AGRICULTURE WELL OTHER WELL JFTPITS/SUMPS <br /> INTENDED USE TYPE DF WELL --'^,PROBEEM-AREA- NS""" "''CONSTRUCTION SPECIFICATIONS <br /> { rr <br /> 0 Industrial U Open Bottom Manteca Dia ,of Well Excavation,ra <br /> Domestic/P_rti-vate. $4-Grayel. Pack_ acy Dia of�Well�Casing ___- -W- - - <br /> �.Public Other Q;Delta Type of Casing <br /> LJ Irrigation 17,F Approx. _ Q Eastern Specifications <br /> �4Cathodic Protection Depth + , <br /> .I f F Depth of Grout Seal 1 <br /> UGeophysical Type of Grout >1�1C1 <br /> U:Other Surface Seal Installed by dA1� <br /> Repa-ir WOrk Done ❑ Type of Pump H.P: State Work Done <br /> Wel 1', Destruction U Well Diameter Sealing'Material (top 50') <br /> a <br /> # Depth �� Filler katerial {Below 50'} <br /> TY ' OH,SEPTIC WORK: NEW INSTALLATION L1 - REPAIR/ADDITION J (No septic'tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installati ill serve: Residence _ Conmiercial Other <br /> Number of living u Number of bedrooms ' Lot size <br /> Character of soil to a dep f 3 feet: �` ater table depth <br /> SERTIC TANK ❑ Type/Mfg Ca.acity No. Compartments <br /> PKG, TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance-to--ne&r-esir Foundation Property Line <br /> J DESTRUCTION <br /> LEACHING'D NE LJ No. gth of lines 1 length/size <br /> FILTER BED..' Distance to nearest: Well Foundation roperty Line <br /> �. <br />' SEEPAGE, P Depth Size Number <br /> S _ U Distance to nearest: Well Foundation Property Line - <br />...•.r-.,�.-: �15POSAL•..PONDS"'.� � .� :_=;.� , ;,,,��„t -_ � _ gib,== - � .. <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 applic m I for_ ll required inspections. Complete dra g on e_rse side <br /> 1 Date: <br /> Signed 'X Title: <br /> �DP �TT S ONLY Q• I Qu:Stk 466-6 1 <br /> Area <br /> Application Accepted by <br /> F <br /> Additional Comments: Lodi 369-3621 <br /> pit or Grout Inspection by Date - 3 '� f D Manteca 823-7104 <br /> Firal Inspection by Date Tracy 835-6385 <br /> Applicasnt - Return all ,copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 <br /> r � <br /> �ERMITN�,� <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE INFO `` � 1f " <br /> r e <br /> J <br /> 's r 10/$2 500 <br /> EH 13-24 REV. 10/82 <br /> 14-25 <br />