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APPLICATION FOR-PERMIT i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA , PERMIT NO. <br /> Telephone (209) 466-6781 _ 1 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSiEO 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 Rules and Regulations of the San Joaquin Local Health District, i <br /> Job Address_ /Y/9.� a �A�,( �� ?tgKF4 y•Subdivision Natty <br /> Owner's Name_OyII r &LxbAddress syotC. Phone <br /> Contractor's Name License No. • — 9 Phone q•r <br /> TYPE OF WELL/PUMP WORK; NEW WELL [] WELL REPLACEMENT ] DESTRUCTION[� <br /> t� <br /> PUMP INSTALLATION [3 -SYSTEM REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TANKS <br /> EWER LINES DISPOSAL FLO. PROP. LICE,{ <br /> FOUNDATION 2 AGRICULTURE WELL OTHER WELL. ,�. PITS/SUMPS <br /> INTENDED":USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IndustrialElOpen Bottom []Manteca 'Dia.wwol1'E'xdavation s <br /> LJ Oomestic/private ❑Gravel- Pack a Tracy Dia, of Well Casing +� <br /> L Public �J Other []Delta <br /> u irrigation Type of Casing .a1 r• <br /> Approx.eth- D Eastern Specifications <br /> L Cathodic Protection Depth- <br /> Geophysical Depth of Grout Seal <br /> 0 Other Type of Grout <br /> r5urface 5_ Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction Well Diameter Sealing4laterial (top 5O') <br /> Depth Filler Material (Below 50') ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> YInstallation xiTlserve; Residence / Commercial -Other - available within 2DO feet.) <br /> _ : <br /> Number of hying units: Numberof;bedrooms ✓? Lot•si,ze <br /> Character of soil to a depth of 3 fee#.� <br /> Water table depth 300 <br /> SEPTIC TANK Lj Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Q'; Type/Mfg �' <br /> } Capacity McVod of Disposal <br /> SEWAGE SYSTEM <br /> DESTRUCTION. Distance'to nearest; Well Foundation Property Line t <br /> ❑ y��•.. <br /> LEACHING LINE No. 5 Length of lines `Total Length/size <br /> FILTER BED } Di'stance'to nearest: We11 /dfl Foundation /O' Property Line A&' <br /> SEEPAC,E-f1TS.--• _ - -Depth Size Number C i <br /> SUMPS U Distance to nearest: Well Foundation _._ Property Line <br /> DISPOSAL PONDS 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 i:he•San Joaquin Locaa• Health District.,,- y„ <br /> Home owner or licensed agent's signature certifies-the 76110wing: "I�certi'fy that in the performance of the work for which this - ! <br /> permit is tissued. I.shall not employ any person in such manner as to become subject to workmant 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 iihich <br /> this permit is issued. I shall employ persons subject to workman's compensation laws of California." <br /> The applicant mum call for all required inspections. Complete drawing_on;-reverse side. <br /> Signed X � _ - ..._..Title: , Date: <br /> OR ENT USE ONLY <br /> Application Accepb r Y Area'+a - [] Stk 466-6781 } <br /> Additional Comments; }.' `[ 'Lodi 369-3621 <br /> Pit or Grout Inspection b _ Date 'Manteca 823-7104 <br /> Final Inspection by y Date ^7-� L Tracy 835-6385 <br /> Applicant - Return all copies to; Environmen T Health Permit/Services 16,01 E. Hazelton Ave., P.A. Box 2009. Stk-, CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIYED BY DATE :PERMIT K0. <br /> EH 13-24 REV. 10/82 : '° ` i ,I D 10/82 Soo <br /> 14-26 <br />