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76. <br /> APPLICATION FOR PERMIT / <br /> SAN JOAQU'i?d LOCAL HEALTH DISTRICT • �"`/' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781 DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ` (Complete in_Triplicate) <br /> n Joaquin Local Health District for a permit to construct and/or install the work herein <br /> Application is hereby made to the Sa <br /> with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weil/pump <br /> described" This application is made in compliance <br /> and the Rules Regulations of th1. San oaquin Local Health District. <br /> rclJab Address r., Subdivision Name <br /> J AddressPhone <br /> Owner's Name Phone 7— <br /> Contractor's Name-" (,C License No. <br /> (I <br /> TYPE OF WELL/PUMP WORK: NEW WELL [f L REPLACEMENT F] _ DESTRUCTION <br /> "PUMP INSTALLATION SYSTEM REPAIR L7 OTHER U <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS \� <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �Y <br /> IExcavation <br /> _Jlndustrial U Open Bottom Q Manteca Dia. of Well ExcaV <br /> ' <br /> mesticlPrivate � Gravel Pack [j- Trac Y Dia. of Well Casing <br /> Publ-c CJ Other Delta Type of Casing <br /> rrigation Approx. Eastern Specifications (� <br /> Cathodic Protection <br /> Depth Depth of Grout Seal r t <br /> Geophysical Type of Grout <br /> U Other Surface Seal Installed by <br /> Type of Pump State Work Done <br /> Repair Work Done D TYP p�- _ <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION jJ (No septic tank or seepage p1availableed if withinu200cfeet.) is <br /> f Installation will serve: Residence Commercial _ Other <br />' Number of bedrooms Lot size <br /> Number of living units: of,bedrooms <br /> table depth <br /> Character of soil to a depth ofi3 feet: No. Compartments <br /> SEPTIC TANK f—I Type/Mfg Capacity <br /> Capacity Method of Disposal <br /> PKG. TREATMENT PLT. [7jType/Mfg Property Line <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation <br /> DESTRUCTION — <br /> Total length size <br /> LEACHING LINE L_j No. & Length of lines <br /> Foundation Property Line <br /> FILTER BED Distance to nearest: Well <br /> � <br /> Depth Size 'Number <br /> SEEPAGE:PITS ❑_ Property Line <br /> SUMPS <br /> LI Distance to nearest: Well Foundation <br /> � � <br /> j DISPOSAL PONDS <br /> I, application and that the work willbe done in accordance with San Joaquin county <br /> I hereby certify that I have prepared this app <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> F 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 uch manner as to become subject to workmank compensation laws of California." <br /> r Contractor' firing or sub-contracting sig ature c r"tifies the following-.' "I certify that in the performance of the workforwhich <br /> this perm is issued, I shall employ er ns sub ect to workman <br /> c a ensation laws of California." <br /> r / c o s. Complete d n on reverse side. <br /> The appli nt ust a or"a I equ" a Da <br /> Signed X Title: <br /> I R DEPART E USEJbLY� � �4 �(gtk 466-6781 a <br /> �'11 r C/ ''F'\L <br /> Application Accepted'ti � odi 369-3621 <br /> 4 <br /> Additional Comments: Date C Manteca 823-7104 <br /> r <br /> P, Grout Inspection by, L Tracy 835-6385 <br /> Date <br /> final I spection by <br /> k A plic - Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA' 95201 <br /> EEEAMOUNT REMITTED RECEIVED BYDATE PERMIT NO. <br /> 171 -A?. y � <br /> 14 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />