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APPLICATION FOR PER[sdT <br />S9.4 JOAQUiN LOCA_ HEALTH DISTRICT <br />1501 E. HA7ELTON AVE., STOCKTON, CA <br />iiTelephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />`il (Complete it Triplicate) <br />PERMIT NO. <br />DATE ISSUED <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 compl.Earce 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 />Joh Address 0. <br />­0� 4Subdivision Name <br />Owner's Name MA 61411 A Address Q �� Phone <br />Contractor's Name � License No. -3 Phone <br />A n A&a11 <br />.TYPE OF WELL/PUMP WORK: NEW WELL' <br />PUMP INSTALLATION <br />DISTANCE TO NEAREST: -SEPTIC TANK <br />FOUNDATION <br />INTENDED USE <br />TYPE OF WELL <br />C Industrial <br />❑ Open Bottom <br />Domestic/Private <br />,� Gravel Pack <br />C Public <br />C Other <br />Ci Irrigation <br />Approx. <br />C Cathodic Protection <br />Depth <br />L7 Geophysical <br />Type of Grout A. [N Te <br />U Other <br />Surface Seal Installed by <br />Repair Work Done C Type of Pump <br />Well Destruction U Well Diameter <br />Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION C <br />Installation Will serve: Residence _ <br />Number of living units: Number <br />Character of soil to a depth of 3 feet: <br />SEPTIC TANK A _ Cj Type/Mfg <br />PKG. TREATMENT PLT.' 0'. Type/Mfg <br />SEWAGE SYSTEM C Distance to near <br />DESTRUCTION <br />LEACHING LINE <br />FILTER BED <br />SEEPAGE PITS <br />SUMPS <br />DISPOSAL PONDS <br />C <br />_C <br />U <br />C <br />U <br />WELL REPLACEMENT DESTRUCTION <br />SYSTEM REPAIR U OTHER ❑ <br />SEWER LINES IStQ DISPOSAL FLO. PROP, LINE <br />AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />PROBLEM AREA <br />CONSTRUCTION SPECIFICATIONS <br />Manteca <br />Dia. of Well Excavation f/ <br />Tracy <br />r <br />Dia..of Well Casing <br />❑ Delta <br />Type of Casing S" TQ c- G <br />C Eastern <br />Specifications M 6 <br />Depth of Grout Seal Z <br />Type of Grout A. [N Te <br />Surface Seal Installed by <br />H.P. <br />State'Work Done . <br />_ Sealing Material <br />(top 501) _ <br />Filler material '(Below <br />50'} <br />EPAIR/,ADDITION C (No septic tank or seepage pit permitted if public sewer is <br />available within 200 feet.) <br />3mmercial Other <br />bedrooms Lot size <br />No. & Length of liines <br />it <br />Distance to nearest: <br />Depth <br />a!, <br />Distance to nearest: <br />J� <br />Well <br />Well <br />Size <br />well <br />Water table depth <br />_ Capacity No. Compartments <br />Capacity Method of Disposal <br />Foundation Property Line <br />Total length/size <br />Foundation Property Line ' <br />Number <br />Foundation Property Line <br />thiso�pplication and that the work will be done in accordance with San Joaquin county <br />I hereby certify that I have prepared <br />ordinances, state laws, and rules and regul`ations of the San Joaquin Local Health District. ork for which this <br />Home owner or licensed agent's signature ce`rtifies the following: "I certify that in the performance of the w <br />permit is issued, I shall not employ any person in such manner as to become subject to workman's 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 />Uhl <br />The applicant must call fo% all required inlspections. Complete drawing on reverse side. <br />1 Signed X -/�7s+ :�I Title: Date: — ��' <br />' DEPARTMENT ONLY.,r <br />Application Accepted by Area / Z- ❑ Stk 466-6781 <br />Additional Comments: <br />Pit or Grout Inspection by <br />Final Inspection by <br />Applicant - Return all copies to:. Envir <br />Lodi 369-3621 <br />Date C Manteca 823-7104 <br />Date ❑ Tracy 835-6385 <br />Health Permit/Services 16 1 E. HIeltc#Ave„ P.O. Box 2009, Stk., CA <br />=BASE AMOUNT DUE , AMOUNT REMITTED RECEIVED BY <br />�S c,n <br />EH 13-24 REV. 10/82 <br />14-26 <br />DATE PERMIT NO. <br />$ ►-1-� 1- a-- <br />tI /Q 4i -4 -it -73 <br />95201 <br />10/82 500 <br />