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APPLICATION FOR PERMIT <br /> [f/f{ SAN JOAQUiN LOCAL HEALTH ,DISTRICT <br /> 1601 E.- HAZELTON AVE., STOCKTON, CA PERMIT NO. 8,3403 <br /> .....Telephone (209) 466-6781 <br /> DATE ISSUED r <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 and Regulations of the San Joaquin Local Health District. <br /> Job Address Subdivision Name (� <br /> Owner's Name Address Phone t�-0 1gy L <br /> Contractor's Name L4gQOP2�_ License No. 44�_c y7 Phone 44,9`397'1 GN <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 FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I ( industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing <br /> ❑ Public ❑ 0ther [] Delta Type of Casing - r <br /> Irrigation Approx. [] Eastern Specifications <br /> Cathodic Protection Depth <br /> F-1 Depth of Grout Seal <br /> ❑Geophysical <br /> Type of Grout <br /> ❑Other <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50`) _ <br /> a <br /> Depth F Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is Q <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other _ r <br /> Number of'libing units: l Number of bedrooms Lot size tkO 3 1 <br /> Character of soil to a depth of 3 feet: �j,Q $/ r,YAA .A" Water table depth �l <br /> SEPTIC TANK E-11-11Type/Mfg [;(? (_ _ Capacity 7--y 0 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg, ' Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance'to nearest: Well Foundation I ' ___ Property Line p� <br /> DESTRUCTION ❑ ° <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest' Well Foundation f Property Line <br /> SEEPAGE PITS DepthSize �`� ' fr Number <br /> SUMPS ❑ Distance to'nearest: Well Foundation Property Line �� t <br /> DISPOSAL PONDS ❑ f-� <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 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 issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant must call for All .requirFed inspe ions. Complete dr�ing on reverse side. <br /> Signed X Title: Date: <br /> FO DEPARTMENT USE ONLY ) <br /> Application Accepted by :4 Area ._._T ❑ Stk 466-6781 <br /> Additional-Comments: } Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by 41PW MIDate ❑ Tracy 835-6385 <br /> Applicant - Return all copies o:,, Environmental Health Permit/Services 1601 E, azelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE .PERMIT NO. <br /> INFO $3-603 <br /> EH 13-24 REV, 10/82 10/82 500 <br /> 14-26 <br /> r <br />