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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT c <br /> 1601 E. RAZELTON AVE., STOCKTON, CA PERMIT NO. - �D _55' <br /> Telephone (209) 466-6781 <br /> " DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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. 1862 for well/pump <br /> and the Rules and Regulations of the. San ,loaquin Local Health District, <br /> Job Address hCMtM,,LWfu1bdivision Name <br /> Owner's Name n y--L �1�� Address Z2p2'� 1V. �j I�tYyyl�}.(( j Phone <br /> Contractor's Name License No. _Phone ) <br /> I <br /> TYPE OF WELL/PUMP WORK: NE4J1.WELL []WELL REPLACEMENT � DESTRUCTION;, s _ <br /> i . . <br /> PUMP-[NST-ALLAiION� SYSTEM-RE"PATR *- = OTHER-U - ,Y-----"--- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F] Industrial U Open Bottom F7Manteca Dia. of Well Excavation <br /> U Domestic/Private F-1 Gravel Pack ❑ Tracy Dia. of Well Casing <br /> 17 Public F-1 Other Delta <br /> 1 Type of Casing , <br /> L i Irrigation Approx. [] Eastern <br /> Cathodic Protection Depth Specifications <br /> Depth of Grout Seal <br /> 17 Geophysical Type of Grout <br /> U Other <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done -A <br /> Well Destruction U Well Diameter Sealing Material (top 50') t <br /> DepthFiller Material (Below 50'} <br /> TYPE OF SEPTIC WORK NEW INSTALLATION U REPAIR/,ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> installation willfserve: Residence _ Commercial _ Other <br /> t: Number of living units: Number of bedrooms Lot size <br /> Character of soi-Zito a depth of,3 feet: Water table depth <br /> SEPTIC TANK J-4 'yyFj Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 10 Type/Mfgj Capacity Method of Disposal :_ <br /> SEWAGE SYSTEM 1 Distance to nearest: Well Foundation— _.,,,,P_roperty L.ine� � <br /> DESTRUCTION P I ,. <br /> LEACHING LINE e' U No. 8 Length of lines I---"'Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> s <br /> SEEPAGE PITS F-1 Depth Size Number <br /> SUMPS Distancet'tc nearest: Well i' "Founda ion Property Line T <br /> DISPOSAL PONDS <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 rules and regulations of the San;JoaquiniLocal Health District. <br /> Home owner or licensed agent's signature certifies the following:`1 certify that in the performance of th'e'.workrfor which this <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmans compensation.laws1of 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." a <br /> The appli nt ust call for all r quired inspections. Complete drawing on reverse side. �{� <br /> Signed X Title: _ Date: 6'�/ f <br /> ication A"'cepted by 0 DEPARTMENT USE ONLY <br /> Area Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or.Grout Inspection by Date LJ Manteca 823-7104 <br /> Final Inspection by Date �" L Tracy 835-6385 <br /> �s <br /> Applicant - Return all copies to: Environtal Health Permit/Services 1601 E. Hazel on A , P.O. Box 2009, Stk., CA 95201 <br /> 11 <br /> rINFO <br /> BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. } <br /> 156s` y� y— Ff- 77 <br /> EH 13-24 REV. 10!82 t -7^r1—&4 10/82 500 <br /> 14-26 <br />