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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH OISTRICT <br /> 1601 E. HAZELTOhJ AVE., STOCKTON, CA PERMIT NO. - 09 <br /> Telephone (204) 466-6781 4_0 <br /> GATE ISSUED <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 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 ?,F e%IV AIAVW-CA Subdivision Name <br /> Owner's Name ZE. JE AZ&gAddress "/ y P.�!A c d Phone <br /> Contractor's Name ,( 57Z License No. P,56-T9_ Phone <br /> OV <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT C DESTRUCTION <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U"Open Bottom' Q Mdntcca - Dia. of Well- Excavation - --- <br /> Domestic/Private C Gravel Pack C{ Tracy Dia. of Well Casing <br /> C Public C Other E] Delta <br /> Irrigation Type of Casing <br /> Li 9 Rpprox. � Eastern <br /> CICathodic Protection Depth Specifications <br /> Depth of Grout Seal <br /> Geophysical I = <br /> Type of Grout <br /> Other Surface Seal'-Cnstalled by <br /> t� <br /> Repair Work 'Done Ci Type of Pump H.R, y'­ ate 'Work•Done <br /> Well Destr� tion U Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF 5bJIC WORK: NEW INSTALLATION U REPAIR/.ADDITION X (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence / Commercial _ Other <br /> Number of living units: �_ Number of bedrooms _ Lot size f j <br /> Character of soil to a depth of 3 feet: b1 L24PA Water table depth L ),r <br /> SEPTIC TANK Type/Mfg � ,L 'Capacityc.: B6 6, 1 No. Compartmetfts,.-_ <br /> PKC. TREATMENT PLT. (] Type/Mfg Capacity! Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Prgperty Line <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines •~' Total I e n g LhJ siie`, � <br /> FILTER BED Distance to nearest: Well FoundationProperty Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation o erty Line <br /> DISPOSAL PONDS <br /> � i iw nuri.�.rir.w.�,i n■ , <br /> I hereby certify that I have'-prepare4 this application and that the work will be done in accprdance 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: "T certify that in•the p6Yformance of-the work for which this <br /> permit is issued, 1 shall not employ any person in such manner as.l:_o become'subject to workrrans•c'ompensation laws of Califorria." <br /> Contractor's hiring or sub-contracting signature certifies the`fol1owing: "I certify tha,f In the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws o-f California." <br /> The applicantmust cal for 11 required inspections. Complete drawing ort-reverse side. <br /> Signed X_ C�tr` ^•� �lui7l Title: ��/ Date: 3�7��� <br /> OR.,DEPARTOENT USE ONLY <br /> Application Accepted by �� �- Area-''1 C Stk 466-6781 <br /> Additional Comments: �r—� C Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by - i1,:Caiw Date (racy 835-6385 <br /> Applicant - Return all top iess t�nmentaI Health Permit/Services 1601 E. Hazelton Ave, P.O. Box 2009, St k., CA 95201 <br /> FEE BASE ; AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 w 10/82 500 I <br /> 14-26 <br />