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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �J <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, b�!(412ql <br /> t Telephone-(209) 466-6781 } v <br /> 11 DATE ISSUED I <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 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 cal Health District. <br /> Job Address Subdivision ame <br /> Owner's Named Address ?hon G2�9 — o7.�so <br /> Contractor's Name License No. Phone o2O <br /> "TRP[ DF WELL/PUMP WORK: NEW WELL --1C11_ WELL REPLACEMENT [] DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TC,NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE - <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ppp��6 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS17 - <br /> Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑Gravel ..Pack T❑ Tracy Dia. of Well Casing <br /> ❑ Public ❑Other ❑ Delta <br /> Irri ation Type of Casing <br /> L! 9 Approx. ❑ Eastern <br /> ❑Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> ❑0ther Type of Grout <br /> Surface Seal-Installed by <br /> Repair Work Done ❑ Type of Pump H.P. T -State Work Done -9 , <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material F(Below,50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION XJ REPAIR/ADDiTION [J-�,(Nof pic <br /> 'septic tank or seepage pit permitted iublsewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial Other f /� <br /> Number of living units: I Number of bedrooms ` 3 Lot'•size � f7L• <br /> Character of soil to a depth of 3 feet: "I Water table depth <br /> SEPTIC TANK_�,.,„�.�_ Type/Mfg.-. Capacity �(p[> No. Compartments <br /> PKG. TREATMENT PLT. --—Type/Mfg,' ' Capacity Method of Disposal -.= <br /> Distance to nearest: Well Foundation-.�:. Property Line <br /> LEACHING LINE + .No. & Length of lines t �Ib Total length/size T� <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> _SEEPAGE­PI•TS__ __Depth-1Q -S.ize..._ <br /> 4X� <br /> SUMPS [Tn-- Distance to nearest: Well �t�Foundation \ �.._ Property Line <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 /> 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 workman s 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 071 fq all required inspections. Complete drawing on reverse side. <br /> Signed 1___L Title: `/�Jy�yfDate: �l <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �ACAreaE] Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621, <br /> Pit or Grout Inspection by Date [ Kanteca 823-7104 <br /> Final Inspection by Date <br /> \\^°\ ^�.. ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental alth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV, 10/82 C� 10/82 500 <br /> 14-26 t LA0 <br /> S <br />