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4 f <br />APPLICATION FOR PERM':T <br />SAN JOAQU01 LOCAL HEALTH DISTRICT <br />1601 E. HAGELTON AVE., STOCKTON, CA PERMIT NO. <br />Telephone (209) 466-5781 <br />f DATE ISSUED <br />PERMIT EXPIRES I YEAR FROM DATE ISSUED CIO QO <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 �p%� S �Subdivision Name <br />Owner's Name C a r (AdiFiv Address Phon- to y <br />Contractor's NamdDTIZCcor<-s S4 d:;,2M4_-4)License No. to -J2 Phone -2 1 V7 <br />TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION U <br />PUMP INSTALLATION SYSTEM REPAIR OTHER L_J <br />DISTANCE TO NEAREST: SEPTIC TANK 16 cl. SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N <br />Industrial pen Bottom Manteca Dia. of Well Excavation <br />j�9omestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing <br />❑ Public ❑ Other ❑ Delta f <br />Irrigation Type of Casing <br />Lf g- © Approx. Eastern f1 <br />Depth Specifications - <br />c). �I <br />Cathodic Protection r T <br />Depth of Grout Seal _ <br />Geophysical e <br />Type of Grout f `? 6, <br />Other <br />Surface Seal Installed by � <br />Repair Work Done El Type of Pump H.P. State Work Done <br />Well Destruction ❑ Well Diameter Sealing Material (top 50') <br />Depth Filler Material (Below 50') <br />TYPE OF SEPTIC WORK: NEW INSTALLATION FI REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br />available within 200 feet.) <br />installation will serve: Residence _ Commercial <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: <br />SEPTIC TANK Type/Mfg <br />PKG. TREATMENT PLT. Type/Mfg <br />SEWAGE SYSTEM Distance to nearest: Well <br />DESTRUCTION ❑ <br />Other <br />Lot size <br />Capacity <br />Capacity <br />Foundation <br />_ Water table depth <br />No. Compartments <br />Method of Disposal <br />Property Line <br />LEACHING LINE ❑ No. & Length of lines Total length/size <br />FILTER BED Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS Depth Size Number <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 workmanh 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 call o all required inspections. Complete drawing on reverse side. t` <br />Signed *�.L Title: oat e: <br />FOR DEPARTMENT USE ONLY l T O <br />Application Accepted by Area 02, Stk 466-6781 <br />Additional Comments: Lodi 369-3621 <br />Pit o Grdut Inspection b Date Manteca 823-7104 <br />Final Inspection by Datey/y L7Tracy 835-6385 <br />Applicant - Return all copies o: En ronmental Health Permit/Services 160 E. Hazelton A'�e., P.O. Box 2009, Stk., CA 95201 <br />FEE BASE AMOUNT DUE <br />AMOUNT REMITTED <br />RECEIVED BY <br />PERMIT N0. <br />I NFO <br />I� <br />�D�ATE <br />EH 13-24 REV. 10/82 ?T Z Tb 10/82 500 <br />14-26 <br />