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4 APPLICATION FOR PERMIT <br /> SAN JOAQbiN LOCAL HEALTH CiSTRICT <br /> �} 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. �? 7 0 Y <br /> Telephone (209) 466-6781 ^-7 <br /> DATE ISSUED f <br /> PERMIT EXPIRES I 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 Re ul Monsp�f the n Joaquin Loca Health District. <br /> Job Address ^{ Jv�� ,1�Yj1� Subdivision Name <br /> Owner's Name �,A �.* �ry.p�n2 Addresson —LXI <br /> Contractor's am1� a cense No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR i ' OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PISS/SUMPS <br /> d <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 71 Industrial U Open Bottom F-1 Manteca Dia, of Well Excavation <br /> IJ Domestic/Private F_� Gravel Pack ❑ Tracy Dia. of Well Casing <br /> D Public [—I Other Delta <br /> irrigation Type of Casing <br /> I—j 9 Approx. Eastern <br /> Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> LJ Type of Grout <br /> ❑Other <br /> Surface Seal, Installed by <br /> Repair Work Done EJ Type of Pump H.P, State Work Done f <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (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: Numbe of bedrooms -� Lot size �j x ci�0 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines Total length/size Vol <br /> FILTER BED Distance to nearest: Well Foundati Property Line <br /> SEEPAGE PITS Depth Size gd� umber + <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS CI <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 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 a far a equired inspe ions. Complete rawing on reverse side. <br /> Signed X Titley Date: <br /> F EPA VENT USE ONLY <br /> Application Accepted by Area U Stk 466- 3 ` <br /> Additional Comments: r C1�7 . Awh. Lodi 36 -3621 <br /> Pit or Grout Inspection by Date 7-1f IJ Manteca 3-7104 <br /> Final Inspection by Date /7- O3 ❑ 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 PERMIT NO. <br /> INFO <br /> 15 773 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />