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APPLICATION FOR PERMI- <br /> SA.N JOA.QUIN LOCAL HEALTH DiSTRIC, <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Teiepnone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXFIRES 1•YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquir. Local Ilealtn District for a permit to Construct and/Dr 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 ,oaquin Local Health District. <br /> Sob Address _: !1lA7�F.@i- .-_^Subdivision Narne _ <br /> Owner's Name ri, q. j�Ctl f��E'gf'C TICS Address !_��F. CL Phone <br /> Contractor's Name 1/Ai zC�l l>♦. G License No. _ _� 33 _ 'hone el 3y�yt?S 1 <br /> TYPE OF WELL/PUMP WORK: NEW WELL F] WELL REPLACEMENT DESTRUCTION 1A <br /> ~ PUMF INSTALLATION 0 SYSTEM REPAIR OTHER u <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSA'- FLO. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ f <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CON57RUCT134 SPECIFICATIONS <br /> Industrial (0 Open Bottom r,4anteca Dia. of Well Excavation <br /> LJ Domestic/Private ❑Gravel Pack [,Tracy Dia. of Well Casinq <br /> L Public U Other Delta Type of Casing _ I <br /> Lj Irrigation Approx. Eastern Specifications — <br /> E)Cathodic Protection Depth <br /> Depth of grout Seal <br /> LJ Geophysical Type of Grout <br /> 1-1 Other Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State 'Work Done �] <br /> Well Destruction (J, Well Diameter _ Sealing Material (top 501) <br /> Depth Filler Material (3elow 501) <br /> TYPE OF SEDTIC WORK: NEW 1NSTALLATIO4 LI REPAIR/ACOITIOY (No septic tank or seepage oiavailableewithinu200cfeet.sewe) is ` <br /> Installation will serve: Residence _ Commercial X_ Otner <br /> Number of living units: Number of bedrooms Lot size <br /> Nater table depth 1 GIS <br /> Character of soil to a depth of 3 feet: C�. <br /> ' <br /> Capacity _Lbooa(dI -4o• Compartments <br /> SEPTIC TANK VC Type/Mfg , —� Capa _ Method of Disposal <br /> PKG. TREATMENT PLT. F], Type/Mfg _ p y <br /> 'SEWAGE SYSTEM' C1 Distance to nearest: Well 121j I Foundation ___A O' Property Line <br /> DESTRUCTION _ - • <br /> LEACHING LINE No. 8 Length of lines 1 Total length/size O G P <br /> FILTER BEDDistance to nearest: Well _ Foundation Property Line _ r` <br /> L. <br /> Depth Size " Number a1 <br /> SEEPAGE PITS �j _._ <br /> SUMPS U <br /> Distance to nearest: Well1 S Q y_Foundation - Property Line <br /> DISPOSAL PONDS <br /> r <br /> I hereby certify that I have prepared this application and that the work will be Gone in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health Oistr`,ct. of <br /> Home owner or licensed agent's signature certifies such`mannernas to certify <br /> come sthat <br /> intthe <br /> performance <br /> nsathonwlawsfof California." <br /> Contractor's permit <br /> is issued, 1 shall not employ any p <br /> Contractor's hiring or sub-contracting signature certifies the following: "i cert'.fy that in the performance of the work for wh cn <br /> this permit is issued, ['shall employ persons subject to workman's compensation laws of California." <br /> The applicant ust call,for all r fired inspections. Complete drawi���averse side. pate: <br /> Signed Xa�_ - _ <br /> Title: G - <br /> OR DEPART Stk 466-6781 <br /> Application Accepted by _Area ��_. <br /> Lodi 369-3621 <br /> Additional Comments- <br /> Manteca Manteca 823-7104 <br /> Fit or Grout :nspec ion b Date <br /> Final Inspection by <br /> _ Date Tracy 835-6385 <br /> Applicant - Return all copies o: Fnv=ronmental heaILh Permit/Services iM., *Ave.. P.O. Box 2009, Stk., CA 95201 _ <br /> E A14OUNT REMITTED RECEIVED BY DATE PERMIT NC. <br /> EE BASE AMOUNT DUE _ <br /> INFO <br /> 10/82 500 <br /> 1 E:1 13-24 REV. 10/82 ' <br /> F 14-26 4 f <br />