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APPLICATION FOR PERMIT *W0 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 4' 3 --'3 7 <br /> ` Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> (Complete in Triplicate) <br /> bw <br /> is <br /> described. Thisapplicationishmaden inocomplianceuin l with Health SanOistrict for a Joaquin CountypermitOrdinance cNo. 549iforand/or <br /> sewageinstall <br /> No. 1862 work <br /> forherein <br /> well <br /> and the Rules and Regulations of the San Joaquin Local Health District. 9 /pump <br /> Job Address /V .%T��T Subdivision Name <br /> r Owner's Name /G Address <br /> Phone <br /> Contractor's Name _ Aaylrtt J•eye License No. 2 1'4/ —_i V:1 Phone y/,G yV07 <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> r PUMP INSTALLATION SYSTEM REPAIR OTHER C U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 <br /> r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS U <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial E] Open Bottom Manteca Dia. of Well Excavation <br /> L 1-1 Domestic/Private Gravel Pack Trac <br /> l7 Public CJ Other Delta - Dia, of Well Casing <br /> Li Irrigation Type of Casing <br /> Apth x. Eastern <br /> 1 <br /> F-1CathodicProtection Depth Specifications <br /> It_ ❑Geophysical Depth of Grout Seal <br /> U Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P, State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below SO') <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION U REPAIR/ADDITION VJ (No septic tank or seepage pit permitted if public sewer is G <br /> r <br /> Installation will serve: Residence/_ Commercial _ Other available within 200 feet.) <br /> Number of living units: Number of bedrooms �_ Lot size <br /> Character of soil to a depth of 3 feet: (�'�.1J-��__ Water table depth 15�o <br /> SEPTIC TANKType/Mfg PL}y;,¢��df Capacity &.CD No. Compartments C <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> V <br /> LEACHING LINE R No. d Length of lines <br /> 9 � I Total length/size &,'p <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line6. v <br /> SEEPAGE PITS E) Depth -2- 5-- Size 7j 3 Number 1, <br /> SUMPS LJ Distance to nearest: Well v Foundation 3:a Property LineY�a <br /> DISPOSAL PONDS ❑ <br /> r <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 workmant compensation laws of California." <br /> 41. 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 cal for all requir ns actions. Complete drawin9 �o verse ide. <br /> Signed X�� yVC p &.lam <br /> �, Title: _ Date: <br /> OR EPARTMENT USE ONLY <br /> Application Accepted pb� - �..p —2u� ; Area Stk 466-6781 <br /> Additional Comments; C7Q7 aac ,pd „ 0 Lodi 369-3621 <br /> on Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by -�^/. e"f _ Date `� .c>r,� Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMI�NO.INFOF_ i <br /> EH 13-24 REV. 10/82 y <br /> 14-26 10/82 500 G� <br />