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1� APPLICATION FOR PERMIT y �' <br /> f SAN JOA%it; LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 ! r <br /> ORTE ISSUED 'J� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED- <br /> {Complete in Triplicate) <br /> Application is hereby made to the San Jdaquin 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 Reg//ula�1til�ons of the San Joaquin Local Health District. v <br /> Job Address Q W N Subdivision Name <br /> Owner's Name Address p0 3 D C 16LI7 Phone « o <br /> -} _ <br /> Contractor's License No. � pc Phone a(4 0--5.1 4 <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR L OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP.'\LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE.. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> Industrial Oper Bottom Manteca Dia. of Well Excavation <br /> L_I Domestic/Private Gravel Pack Tracy -Dia. of Well Casing <br /> L7 Public F-1 Other Delta Type of Casing <br /> V Irrigation Approx. Eastern <br /> Cathodic Protection <br /> Depth Specifications <br /> Depth-of-Grout-Seal <br /> 1---' Geophysical <br /> Type of Grout _ <br /> Other Surface Seal Installed <br /> Repair Work Done FJ Type of Pump H.P., State Work Done-� <br /> Well Destruction U Well Diameter Sealing Materi,,al r(top _501) <br /> Depth Filler Material (Below 50')' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION E REPAIR/;ADDITION' J (No septic tank or seepage pit permitted if public sewer is p� <br /> // y-- ---- available within 200 feet.) <br /> , <br /> Installation will serve: Residence . Commerclal "' Other . <br /> Number of living units: �_ Number of be rcbms s 'Lot size G14) Q.C� <br /> Character of soil to a depth of 3 feet: . �"' i Water table depth .Q� ET <br /> SEPTIC TANK Type/Mfg Capacity �Q No. Compartments <br /> PKG. TREATMENT PLT. D Type/Mfg •capacity Method of Disposal } <br /> SEWAGE SYSTEM Distance to nearest: W0,1 -Foundation Property <br /> Line !^ <br /> DESTRUCTION Q <br /> LEACHING LINE No, & Length of lines ® ct Total length/size 10 <br /> L �!. <br /> FILTER BED a' F,Distance�to.:nearest:. Well IJ l Foundation e10 Property Line <br /> SEEPAGE PITS Depth - f/Size Number 1 � <br /> j SUMPS Distance to nearest: Well 166V Foundation /Q Property Line ,157 'I- <br /> DISPOSAL PONDS <br /> I 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 rulesleand 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_notlmploy any person in such manner as to become subject to workmanis compensation laws of California." <br /> Contractor's <br /> rasluor, utsignature certifies the <br /> following: <br /> certify that in the <br /> performance of the worcfor which <br /> this permit employ persons subjecttoworkman'scompensationlaws of California." <br /> The applic t must c r all required inspections. Complete drawing on reverse side, r} f <br /> Signed :Ppl <br /> ; Title: ��.�. Date:pC d <br /> FOR DEPARTMENT USE ONLY <br /> zc�ion Accepted by Area Stk 466-fi781 <br /> Addit-iordl Comments: GL.. Lodi 369-3621 <br /> Pl.e or Grout Inspection b n Date Manteca 823-7104 <br /> i Date L Tracy 835-6385 <br /> Final Inspection by <br /> - Appl-icant - Return all copies to: :-,Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> =� BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO <br /> e' <br /> EH 13-24 REV. 10/82 10/,82 500 <br /> 14-26 <br /> f <br />