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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ,yam <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �/pV <br /> Telephone {209} 466-6781 DATE ISSUED ..p� <br /> I�C"''ter PERMIT EXPIRES 1 YEAR FROM DATE [SSU ED - <br /> �_ r <br /> ic <br /> Applicat"This <br /> made to the San Joaquin Local Health'District for a permit to construct and/or install the work herein <br /> describecation 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 Joaqu'n L al Health District. <br /> Job Address ar`I/ Subdivision Name <br /> Owner's Name Address Vy Q <br /> Contractor's Name", ' License No. i S�*7"s 4G 2 Phone Z` <br /> i <br /> TYPE OF WELL/PUMP WORK: NEWIWELL WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.1 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM:AREA .CONSTRUCTION SPECIFICATIONS' n <br /> F ; <br /> industrial U Open}Bottom Manteca Dia.-of Well Excavation r <br /> U Domestic/Private Gravel Pack Tracy Dia.-of Well Casing <br /> PublicOther E] Deltan R' ! <br /> Type of`Casing <br /> Lj Irrigation Approx. Eastern <br /> Depth Specifications <br /> Cathodic Protection w <br /> -Oepth,of Grout Seal <br /> 17 Geophysical _ <br /> Other � TYPe of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> t <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> k <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [:I REPAIR/ADDITION (No septic tank of seepage pit permitted if public sewer is <br /> e s/ ,'/__ _ _ oval ble within 200 feet.) <br /> ' Installation will serve: Residence _ Commercial Other `l/[B•{�4,(/ /�7llYdt� <br /> Number of living units. Number of bedrooms _ Lot size <br /> .rL t <br /> Character of soil to a depth of'3 feet: ��K 1� _ Water table depth <br /> SEPTIC TANK Type/Mfg' Capacity s 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 F-1 No. & Length of lines _ 1 Total length/size <br /> FILTER BED E:] Distance to nearest: Wel 4640 106 Foundation Property Line <br /> SEEPAGE PITS Depth hSize Number <br /> t ! 7Property Line <br /> l <br /> SUMPS LJ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ h <br /> I hereby certify that I have prepared this application and that the work will`..be done in accordance with San Joaquin county <br /> ordinances, state laws, and rulesland regulations of the San Joaquin Local Health District. a <br /> Home owner or licensed agent's signature certifies the following: "I certify that i'n 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 compensation laws of California-" <br /> Contractor's hi 'ng or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> E this permit is i sued, I shall employ persons suAllect to workman's compensation laws of California." <br /> The applica 1 for 1 re i ct' ns. " <br /> omple dr on reverse side. <br /> Signed X itIe: Date: <br /> R <br /> PARTKNT USE ONLY 0� <br /> Are Stk 4fi6-6781 <br /> Application Accepted by a <br /> Additional Comments: O'er Lodi 369-3621 <br /> Date lo.� Manteca 823-7104 <br /> Pit or Grout.Inspection by LL <br /> Final Inspection by Date lG Tracy 835-6385 <br /> Applicant - Return all copies to: - Environmental 'Health Permit/Services 1601,E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> FEE ASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE�s Q PERMIT NO. <br /> INFO ��� �� ,• . � - (y l�"o,3 O � a <br /> EH 13-24 REV. 10/82 <br /> 10/82 500 - <br /> 14-2b <br /> k <br />