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Yl <br /> APPLICATI;DN FOR PERMIT <br /> SAN JOAQUN'LDCAL HEALTH DISTRICT <br /> I , 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. I� f'.o <br /> 1 Y Telephone (209) 466-6781- DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v, <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. 544 far sewage or No. 1862 for well/pump <br /> t <br /> he San Joaquin n Local Hea th District. <br /> Rules and Re ulation of 4 <br /> and the u 9 _ <br /> Job Address <br /> } <br /> Address Phone <br /> Owner's Name s <br /> Contractor'sAam �+W�' License No• Phone <br /> o0 <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR F-1 OTHER } <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSRL FCD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �{ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS, <br /> — Dia. of We11' Excavati:on <br /> Industrial U Open Bottom Manteca <br /> LJ Domestic/Private D Gravel Pack Tracy Dla. of Well Casing <br /> Public [Other Delta Type of Casing <br /> Irrigation Approx. [] Eastern Specifications - <br /> �, d Cathodic Protection Depth <br /> Depth of Grout Seal � <br /> 6 Geophysical Type of Grout <br /> U Other Surface Seal Installed by1 R 1 <br /> Repair Work Done ❑ Type of Pump H.P, State Work Dane ' 1 <br /> i Sealing Material (top-50') — <br /> I Well Destruction ❑ Well Diameter 9 ,. <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (No septic tank or"seepage piavae'prmittepublic <br /> fsewer <br /> is <br /> lablewithin <br /> Installation will serve: Residence Commercial _ Others <br /> Number of living units: �. Lot size <br /> Number of bedrooms-- � �'�_ �� <br /> Water table depth <br /> Character of soil to a depth of,3 feet:t <br /> SEPTIC TANK yj Type/Mfg �s�sta <br /> �� Capacity � No. Compartments <br /> - Capacity Method of Disposal <br /> PKG. TREATMENT'PLf.'O Type/Mfg <br /> SEWAGE SYSTEM ❑ Distance to.nearesf: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines / 100, fY"� 3 d al. Iengt /size 40U ! <br /> FILTER BED Distance to nearest: Well a.00" Foundation /0�= Property Line <br /> SEEPAGEPITS Depth ZS Size ��+� y Number <br /> .a� <br /> SUMPS <br /> Distance to nearest: Well Foundation Property Line <br /> U' <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with,San Joaquin county <br /> 1 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, F 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 �_a <br /> mploy per ons subject to workman's compensation laws of California." <br /> The applic t call ections. Complete drawingon reverse side. L <br /> / Title: �L�!'C�!%� Date: T <br /> R O ARTMENT USE ONLY Stk 4fi6-6761 <br /> Application Accepted by Area <br /> Lodi 369-3621 <br /> Additional Comments: Manteca B23-7104 <br /> ( Pit or Grout Inspection by Date z—= <br /> IfDate .591- �� L Tracy 835-6385 <br /> Final Inspection by <br /> Applicant - Return all copies to:. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95291 <br /> I PERMIT N0. <br /> FFETSE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE ' <br /> f'� ff S U y (a 3 <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 ' <br /> 14-26 � �C_!- � C_�- - <br /> t <br />