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APPLICATION FOR PERMIT ® 'r/ <br /> SAN JOAQUi„' LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE. STOCKTON, CA ��� + PERN]j NO. <br /> Telephone (2C9) 466-6781 11 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED E�v��(}Nt�'$�Rv 0A ISSUED <br /> (Complete in Triplicate) ?iv, 1L <br /> Application is hereby made to the San Joaquin -Lccal Health District for a permit to construct and/or install the work herein 3 <br /> described. Thi plicaion is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and.the Rules actions of the San Joaquin Local Health District. ��. <br /> Job Address_ S. SFRN kD- ,--_ Subdivision Name ZS (q t}0 ) <br /> Owner's Name 2NMW &M Ee Address 17.0 7S, SJW, Phone <br /> Contractor's Name /,(f ansa No. - — Phone +7 <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ al <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES ti"-- DISPOSAL FLO.` PROP. LINE-20/-7— <br /> FOUNDATION <br /> INE-20/-7—FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �----- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> } J ❑Open Bottom ❑Manteca ,. � : Dia. of Well Excavation <br /> Domestic/Private A' <br /> TLJ ]aGravel-:Pack----� Tracy..---: — Dia. of'Wel1-Casi.ng•.-��.= .�� __ _-- � -� � . <br /> Public El Other Delta <br /> NiK Irrigation QQ Approx. stern Type of Casing 4WI44L <br /> Specifications <br /> Ell Cathodic Protection Depth P <br /> Depth of Grout Seal <br /> ❑ Geophysical <br /> U Type of Grout <br /> Other <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') — <br /> t <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION j� (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 <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 U No. & Length of lines Total length/size y <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work will be done in acc6rdance 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 workmanIs 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, shall employ persons subject to workman's compensation laws of California." <br /> The app]ica us l for a required. inspections. Complete drawl on ravea side. ; <br /> Signed X Title: Date: <br /> DEPARTM T ! <br /> Application Accepted by Area Stk 466-6781 <br /> Additional Comments: Lodi 369-362 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspectior by Date /p- � ,� Tracy 835-6385 <br /> Applicant - Return all copies to: Env' o ental Health Permit/Services 1601 E. Hazelton Ave.,:P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE SASE AMOUNT DUE AMOUNT R MITTED RECEIVED BY DATE: PERMIT N0. <br /> INFO <br /> EH 13-24 REV. 10/82 F-ep, 10/82 500 <br /> 14-26 <br />