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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA. PERMIT NO. —CL✓- - r, r Telephone (209)(209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM GATE ISSUED <br /> Zti <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joag0 n 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 Q z'Z� (-: Y-WM iTF _ Subdivision Name <br /> Owner's Name F �} . Rttm r�g YAddress 10501 E 92,3— <br /> Contractor's Name License No. 'Phone <br /> TYPE WELL PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION Vv I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS O� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial Open Bottom Manteca Dia. of Well Excavation <br /> Lf Domestic/Private ❑ Gravel Pack ❑ Tracy Dia.�of�Well-Casing- ... ..« <br /> Public Ej Other ❑ Delta <br /> ❑ Irrigation R'', Approx. Eastern Type of Casing i <br /> ❑Cathodic Protection Depth Specifications ; <br /> Depth of Grout Seal <br /> E]Geophysical 6. <br /> Other Type oGrout1­1 - <br /> Surface Seal Installed by"Vt.A I <br /> } Y _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction g] Well Diameter Sealing,Materiall(top 50') <br /> Depth Filler 'Material (Bellow-50') I N <br /> tttt c� h <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/AODI�ION Lj (No ss ptic tank or seepage pit permitted ifjpublic sewer is <br /> 0 available within 200 feet.) <br /> Installation will serve: Residence _ Commercial Other <br /> Number of living units: Number of bedrooms Lot,size F f <br /> Character of soil to a depth of 3 feet: w Water table depth <br /> SEPTIC TANK �j Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity - Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well raw ` ' a .t ` <br /> DESTRUCTION ❑ Foundation Property Line t <br /> LEACHING LINE F-1 No. & Length,of_lines w:l t3 Total length/size <br /> FILTER BED ❑ Distance to nearest:'*Well. Foundation r ; ',Property Line # <br /> SEEPAGE,PITS ❑ Depth Size , Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL:PONDSEJ <br /> ,, +� <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 th*e 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 t 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 s employ persons subject fo workman's compensation laws of California." <br /> fThe applican mus 1 f 1 required in p tions. Complete drawing on reverse side. <br /> Signed X I A3 Title: (04AJ %Q/1/ _ Date: 10-1Z I 8.3 <br /> PARTMENTLISE .ONLY �(�.[.. �! <br /> Application Accepted by Are�a�� 0 Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 V <br /> Pit or Grout Inspectio �iDate 4 3 i 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 BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE YPERMIT NO. <br /> INFO <br /> i <br /> 3� <br /> EH 13-24 REV. 10/$2j 3� r 10/82 500 <br /> 14-26 <br />