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s APPLICATION N <br /> D FOR O PERMIT I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �� <br /> 1601 E. HAZELTON AVE., STOCKTON, CAPERMIT NO. ��,.� I <br /> Telephone (209) 466-6781 / <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED Ift <br /> ���y-�� S77Q-�,`�Sj�•.- -- (Complete in Triplicate) �0 <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. I862 for welll amp <br /> and the Rules a tReulo the JoaqLuin Local Health District. <br /> Jab Address Subdivision Name <br /> Owner's Name Address Phone <br /> Contractor's Name License No. Phone <br /> 913,1447 <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> ):PUMP;INSTALLATION SYSTEM REPAIR OTHER 0 1 <br /> DISTANCE TO NEAREST,' SEPTIC 'TANK SEWER LINES DISPOSAL FLp. PROP. LINE R s <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> Industrial Open BottomWell �r• ' ' �'" <br /> U (]Manteca Dia. of Excavation + r <br /> I_} Dome'sticlPrivate Gravel Pack EJ Tracy Dia. of Well Casing': <br /> I Publis E]Other ❑ Del to <br /> Lj Irrigation Type of Casing <br /> Approx. ❑ Eastern <br /> Cathodic Protect-ion Specifications <br /> �..._ P <br /> Geophysical y �_Ileptb.of,vfrout.,SftlA <br /> LJ Other Type of Gi-but <br /> s r. Surface Seal Instal ed by t <br /> Repair Work Done Type of Pump H.P. State Work Done _ <br /> Well Destruction Well Diameter <br /> ❑._- Sealing terial (top <br /> Depth Filler Material (Belo+r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION Lf (444o(sept: tank or seepage pit permitted if public sewer is <br /> �.ts1r+*,`, i available within 20O feet.) <br /> Installation will serve: Residence _ Commercial t940 + M <br /> i <br /> Number'of living units: Number of bedrooms Lot`'S zi>-A;! <br /> Character of soi to a depth of 3 feet:. ; ) Water kdepth 2 <br /> SEPTIC TANK Ty�e/Mfg Capacity ' &F Compartments <br /> Capacity" <br /> hod of Disposal 7- <br /> PKG. TREATMENT PLT! T yPe Mf9 <br /> SEWAGE SYSTEM Dilstance.to nearest: Well Foundatio Prdperty Line ? <br /> DESTRUCTION <br /> LEACHING LINE ' No. & Length of lines Total 1 n th s ze 3 ; <br /> FILTER SED Distance to nearest; —Property Wel ». Line' _ € <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS L� Distance to nearest: Well Foundation Property Line r 4r <br /> DISPOSAL PONDS ' <br /> I hereby certify that I have prepared this application and that;the krk-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 certUy that in the'perfprmance of the work for which this <br /> permit is issued, 'l shall not employ any person in such manner as to bkome subject to workman. compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following, "I certify that in Che performance of the work for which <br /> this permit is issued,. l sh811 employ persons subject to workman's compensation laws of California." E <br /> The applicant usI call for,alr7%Nuired inspection Com plete"dr'awing--on reverse side.; <br /> r y <br /> Signed X Title: Date: � <br /> ,.+} C�,OR� RT T USE ONLY <br /> Application Accepted by A,- Area .2 Stk 466-6781' <br /> Additional Comments: ' �/ , .? L; y Lodi 369-3621 f{ <br /> Pit or Grout Inspection by Date Manteca 823=7104 ` <br /> Final Inspection by' Date ~ , L Tracy 835=6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.`, Q.O. Box 2009, ttk., CA 95201 � E <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY' D TE PERMIT;NO. <br /> INFD <br /> EH 13-24 REV. 10/8210/82 500 <br /> 14-26 <br />