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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT -15 <br /> $ <br /> 97- (0573 <br /> 5 ✓ 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED —L <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 anG/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 i4effe <br /> Address Phone gS/�-� � w <br /> Cont ractor's Name //_-•-�Zor.-Sn( �1eM02 License No. r Phone vow 9�,3,9 457N <br /> J <br /> TYPE OF WELL/PUMP WO NEW WELL WELL REPLACEMENT DESTRUCTION _ <br /> 11 aF_ 1[+EON. PUMP INSTALLATION j SYSTEM REPAIR OTHER U <br /> DISTANCE_T0­NEAREST:_SEPTICMTANK SEWER LINES f DISPOSAL FLD. PROP. LINE <br /> FOUNDATION '� RICULTURE WELL, ii OTHER WELL Yee PITS/SUMPS <br /> INTENDED USE TYPE OF WELL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> =� Industrial U Open Bottom Manteca Dia. of Well Excavation /,2 if <br /> Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> El Public EJ Other Delta Type of Casing - <br /> Irrigation 9wf Approx. Eastern Specifications <br /> Q Cathodic Protection Depth <br /> r Depth of Grout Seal <br /> ip Geophysical {� Type of Grout i <br /> U Other f Surface Seal Installed by ;1111 <br /> Repair Work Done [J Type of Pump h.P. State Work Done <br /> t <br /> well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/AODITION (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve w�Resjdence _ Commercial _ Other <br /> Number of living units:; Number of bedrooms Lot size <br /> i Character of soil to a,rdepth,of 3 feet:. Water table depth }� <br /> SEPTIC TANK= T/pe%M g t Capacity No. Compartments �J <br /> PKG. TREATMENT PLT. � T.ype/Mfg,,_ Capacity Method of Disposal ® , <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line 1 <br /> DESTRUCTION <br /> i' LEACHING LINE jJ No.y$ Length of lines Total length/size <br /> FILTER BED F7 Distance to nearesti-rWell Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS i <br /> r ; <br /> I I�ereby certify that I have prepared thys application and that the work will be done in accordance with San Joaquin county j <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. t <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'i`s"issued-+I-shal'1 rDt*empl`oy^anylperson 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 t <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant;69 caA for re u' edlinspections. Complete dra n on�a side. p. ; <br /> Signed X Title: Date: 7 O <br /> F R ARTME USE ONLY J <br /> t Application ccepted by a� Area - � [_� Stk 466-6781 <br /> r ❑ Lodi 369-3621 <br /> Addition omments: <br /> Pit Grout I pection by r •1-_ v Date 7-/Z-,53 Manteca 823-7104 <br /> Final Inspection by ' s'r ,a ' Date Z-12 -JF-3 Tracy 835-6385 <br /> I Applicant - Return all copies to:. Environmental health Permit/Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 95201 <br /> i <br /> # {—.AMOUNTRECEIVED BY DATE PERM�NO.F-INFC- <br /> 10 <br /> BASE K-- AMOl1NT 'DUE- �' �'�r • <br /> EH 13-24 REV. 10/82 /S2 500 <br /> ,14-26 <br /> i <br />