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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE,, STOCKTON, CA PERMIT NO. giA—'L_3--73 <br /> Telephone (209) 466-26781: 'x, <br /> DATE ISSUED 3l5%gad <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 /> ,lob Address� Subdivision Name <br /> Owner's Name + iii�t�ed / Address Phone <br /> Contractor's Name AXL,p 1D License No. �E Irk(� Phone q4.S% J`} <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR L7 OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/.SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i2 <br /> L Industrial U Open Bottom Manteca Dia. of Well Excavation ' <br /> 1-1 Domestic/Private ❑ Gravel Pack L Tracy Dia. of Well Casing <br /> Public F-1 other Delta Type of Casing <br /> V Irrigation Approx, L Eastern Specifications t <br /> it ❑Cathodic Protection Depth �+1 <br /> Depth of Grout Seal ` <br /> 17 Geophysical Type of Grout N <br /> U Other Surface Seal Installed by <br /> Repair Work Done LJ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') V y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/,ADDITION .11(No septic tank or seepage pit permitted if public sewer is I" <br /> / available within 200 feet.) <br /> Installation will serve: Residence r -Commercial Other <br /> Number of living units: Number of bedrooms Lot size JO 4 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK L Type/Mfg a{_` 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 /> t LEACHING LINE No. & Length of lines Total length/size ;9 "X 2 <br /> FILTER BED ❑ Distance to nearest: Well Foundation 4—Alp Property Line 3c) <br /> SEEPAGEPITSDepth �. Size3 �' _ Number l <br /> SUMPS L Distance to nearest: Well j'QT Foundation � Property Line _ <br /> DISPOSAL PONDS . <br /> .�_._.w__ <br /> I hereby certify,that ] have prepared this application and that the Wbrk'will be done, in accordance with San Joaquin county <br /> ordinances, state laws and rules and,regulationsiof thertSan Joaquin Local Health District. -+ <br /> Home owner or licensed agent's signature certifies the Fallowing: "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 a5;-to become subject"to workman s. compensation laws of California." <br /> r Contractor's hiring or sub-contracting signature certifies the following: "I certify that-in the`..performance of the work for which <br /> F this permit is issued, I shall employ,persons subject to'workman's compensation laws of California."' <br /> The applicant must call for all requied inspect' ns, Co pl`ete drai'ng on= <br />