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.d APPL IC,:TlON FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRIC7 <br /> 1601 E. HAZELTON AVE.. STOCKTON, CA PERMIT N0. <br /> iclrphone (209) 466-6781 1 <br /> ►+ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0A7E ISSUED <br /> 1 <br /> (Complete in Triplicate) <br /> Application is hereby made to the San ioaquin 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 Joaquin j.gcal Health District. <br /> Job Address_ " �. Subdivision Name <br /> Owner's name GLyac�✓ Address,��?� z� >Yn/. ✓mac / Phon G9�Ys _2_7 p <br /> Contractor's Name " " Phone �J0 9 <br /> License No. __� � <br /> TYPE OF WELL/PUMP WORK: NEW WELL —W"" WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION (J SYSTEM REPAIR ❑ OTHER lJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGR:ZULTURE WELL OTHER WELL PITS/SUMPS <br /> + INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> (� Industrial (�Open Bottom Manteca Ola, of Well Excavation <br /> c <br /> 17 Domestic/Private Gravel Pack F-1 Tracy Dia. of Well Casing 4 <br /> i17 Public l_I Other CJ Deita <br /> Irrigation Type of Casing <br /> V 9 Approx. Eastern Specifications <br /> r7 Cathodic Protection Depth <br /> ` Oepth of Grout Seal <br /> !_)Geophysical <br /> r <br /> 17 Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done 9- <br /> Well <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ] REPAIR/ADDITiON U (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence _ Commercial _ Other available within 200 feet.) <br /> /�, <br /> Number of living units: I Number of b ooms ? Lot size �1�C/ At:. y <br /> Character of soil to a depth of 3 feet: Water table depth 4 Q , <br /> i SEPTIC TANK Type/Mfg C Capacity C�r_i No. Compartments Z. t <br /> PKG. TREATFENT PLT. Type/Mfg Capacity Method of Disposal <br /> Distance to nearest: Well Foundation Property Line { <br /> LEACHING LINE IF< No. 6 Length of lines C71� Total length/size C) <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS --11f6,Depth \Q Size x Number <br /> SUMPS W Distance to nearest: Well Qot4 Foundation Property Line lel, i- <br /> DiSPOSAL PONDS D <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 Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: '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 workmans 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 /> The applicant must 1 all required inspections. Complete drawing n reverse side. / <br /> Signed X (�.Vj - _ Title: ` Date: <br /> FOR DEPARTMENT USE ONL:' u <br /> Application Accepted by ( M' AreaL� Stk 466-6781 . <br /> T-fff ❑ <br /> Additional Comments: Lodi 369-7621 <br /> p <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date \\"11- C] Tracy E::s[..oil 5 <br /> Applicant - Return all copies to: Envirormaental alth Permit/Services 1601 E. Hazeltcn Ave., P.O. Box 2009, Stk., CA 95201 <br /> 4 <br /> FEE BASE AMOUNT DUE I AWUNT REMITTED I RECEIVED BY DATE I PERMIT 40. <br /> INFO <br /> CH 113-24 4-26 REV. 10/82 � �,i ��+ I "� 10/82 500 /-�q <br />