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-Ilk <br /> --,+APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 93 <br /> ' Telephone (209) 466-6781 <br /> DATE ISSUED *1 1 X IY <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7— -7 <br /> r. # (Complete in Triplicate) n <br /> Application is hereby made to Jsan Joaquin Local Health District for a permit•ta 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. f the San.Joaqu n Local Health_District, <br /> Jab Address Subdivision Name, <br /> Owner's Name Idress Phone <br /> +r <br /> Contractor's Name ense No: Phone <br /> 149. <br /> TYPE OF WELL/PUMP WORK: NEW::WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR' � ' OTHER 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS wl'' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> FI Industrial U Open Bottom Manteca,' Dia. of Well Excavation <br /> ? IJ Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public Other E] Delta Type of Casing <br /> V irrigation # �Approx, Eastern Specifications <br /> ❑ <br /> Cathodic Protection Depth Oepth;of,Grout.sealr , <br /> Q Geophysical Type of Grout <br /> U Other Surface Seal Installed by <br /> 'Repair Work Done [_J Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter}. sealing Material (top 50') U) <br /> Depth # F Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION U (No septic;tankor seepage pit permitted if public sewer is <br /> 1 }{ i yVavailable within 200 feet.) <br /> Installation will serve: Residence#� Commercial _ Other A <br /> 'c.Number of. living units: & Number of bedrooms Lot size V C�-- <br /> t=.>• Character df•,soil to-a depth of-3 feet: Water table depth U <br /> SEPTIC TANK �.�j Type/Mfg Capacity ilo. Compartments <br /> 'Method of Disposal <br /> Capacity PKG, TREATMENT PLT. � Type/Mfg � <br /> SEWAGE SYSTEM Distance to�nearest: Well Foundation. Property Line _ <br />[ DESTRUCTION , . -* <br /> LEACHING LINE# No, &Length of lines Total-�ength/size <br /> q FILTER BED Distance to nearest: Wel 1� Foundation Property Line <br /> 1' <br /> ' SEEPAGE PITS � � Qepth _-.!9 bi Size Number � -- <br /> SUMPS Distarr e.to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> r <br /> I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> �y 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 as to become subject to workman compensatibn'llaws 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 em Toy persons subject to workman's compensation laws of California." <br /> "! The applican st 1 all q ired inspecti s Complete drawing on reverse side. G <br /> Signed X Title: Date: T O 3 <br /> FO EP MENT USE dNLY <br /> Application Accepted by Area <br /> + i ` ❑ Lodi 369-3621 <br /> Additional Comments. , <br /> Date Manteca 823-7104 <br /> Pit or Grout Inspection hy' V�cm WHa,eltan <br /> Final Inspection by �,,.. — Date L7 Tracy $35-b385 <br /> Applicant - Return all copies to: . Environmental Health Permit/,Services 160 Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT jDUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> IN <br /> I-{ l B 83 B3- �3_ <br /> 1 ' 10/8z 500 <br /> EH 13-24 REV. 10/82 <br /> 1 <br /> 14-26 <br />