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APPLICATION FOR PERN17 N Al O y �/ <br /> SAN JOAQLa; LOCAL n=-.LTH DISTRICT <br /> / <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. S*4—P'6 <br /> Telephone (?09) 465-6781 <br /> DATE ISSUED —1 <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 RulesyL7n�d Regulations of the San Joaquin Local Health District, <br /> Job Address] F_ pf � A{2_ F_ Subdivision Name <br /> Owner's Name YN ( 144r Address Phone <br /> Contractor's Name 2/+y�� h 12 M JkV License No. Lf ?�t 2.f,ft Phone <br /> TYPE OF WELL/PUMP WORK: NE4! WEL WELL REPLACEMENT OESTkUCTION El <br /> PUMP I ATION SYSTEM REPAIR ❑ OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �I17 Industrial U Open Bottom Manteca Dia, of Well Excavation�• �Ii' <br /> p{LOomestic/Private Gravel Pack r� Dia, of Well Casing /'y//�� <br /> Public Other Delta Type of Casing (/ C�- <br /> Lj Irrigation Approx. Eastern <br /> Depth Specifications <br /> ❑Cathodic Protection Depth of Grout Seal <br /> N <br /> ❑Geophysical Type of Grout <br /> LJ Other Surface Seal Installed by oefie n-P` <br /> Repair Work Done Q Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is 7 <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity 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 ❑ No. & Length of lines Total length/size <br /> FILTER BED El Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <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 Joaquin Local Health District. <br /> Hone 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 workman4 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 applican t ccaaCll for ill required inspections. Complete drawl.n/g,J.on reverse side. <br /> Signed X /L I ' Title: v Date: <br /> PARTMENT USE Y �� y ❑ <br /> Application Accepted by Area Stk 466-6781 <br /> Additional Comments: OF Lodi 369-3621 <br /> Pit or Grout Inspection by Dates � MManteca 823-7104 <br /> Final Inspection by a CT Date. racy 835-6385 <br /> Applicant - Return all copies to: nvironmental Health Permit/Services 16 1 E. Ha elton Ave., P.O. Box 2009, Stk., CA 95201 <br /> [INFO <br /> BASE AMOUNT DUE AMOUNT REMITTED RECEEIVED BY DATE 'PERMIT <br /> , NNO. <br /> 7•(I- `T> <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />