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I! APPLICATION FOR PERIMI T <br /> SAN JOAQUi" LOCAL HEALTH D,ST,RICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I� <br /> X00 [r {Com]gte in Tri plicate) <br /> 1 �,r �S��IU�. <br /> Application is hereby made oto the San Joa�in Local Hea th District far a permit to construct and/or install the work herein <br /> described.. This application is made in 7fompliance with San Joaquin County Ordinance No 49 or sew a or No. 1862 for well/pump <br /> and the Rules a d Regula on .of the San Joaau n L c�a^ll He lth District. .�.� Jr� �y�ar✓ y� <br /> Job Address �� �Q4 ""�' Subdivision Name <br />` - <br /> ' Ne <br /> Owners am <br /> I Phone <br /> Con tractor`s,Name /li License No. <br /> f <br /> TYPE OF WELL/PUMP WORK: ii NEW WELL WELL REPLACEMENT Q DESTRUCTION U <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR l7 OTHER ❑ <br /> �. ',DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLD.. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL -. .PITS/SUMPS <br /> G <br /> t[ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ihdus'trial U Open Bottom ❑Manteca- , Oia. o Well Excavation !_ <br /> iDia. of�Well Casjnq cl _ A, <br /> U Domestic/Private ��Gravel Pack ,Q Tracy <br /> Public IF Other Delta Type of Casing <br /> j Irrigation i Approx. ❑ Eastern Specifications% # <br /> Gathod'ic ProtectidnjG` '-j Dep y ,, ; Depth of Grout.Seal r <br /> Geophysical ! :Type of Grout <br /> Other :"' Surface Seal Installed by G <br /> y <br /> • 1 '1 "'� ,., �. T � StateF Work Dane <br /> Repair Work Llone G'" <br /> Type Pumps } �_.: `3 H:P. <br /> Well Destruction U WellIDiameter Sealing Material (top 501) M <br /> h <br /> Dept k i -z` _Filler Materia r{Bel�owf50')�' <br /> �.�. <br /> TYPE-,OF SEPTIC WORK: NEW.INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> 1 � available within 200 feet.) <br /> ,�Installation,�will serve; Residence Camrnercial i0thir, f. 1 <br /> Number of living units,' � Number of bedrooms Lot size r ` <br /> Character of soil-to-a;depth,of�3 feet;_ <br /> - - -® - _ ~ —..._.Waterrta,�b;.e..depth 1 <br /> Type/Mfg <� C9m�('��Y Capacityµ .y ,�? �b• Compartments <br /> SEPTIC-TANK ) i 1 <br /> PKG.'TREATMENT PLT. �� Type"/M'f9'— /�� <br /> 77W A, Capacity Method of Disposal - <br /> SEWAGE SYSTEMrDistance•to nearest: Well L_o�-- undation Property Line I <br /> F DESTRUCTION �II-- . - i' :-sig <br /> 51 <br /> No. & Length of lines `Total le:.gp/size F <br /> LEACHING LINE X 11 g f �� pc�i�ee <br /> ( FILTER BEd '! Distance to nearest: Well- Founddaation Property Line <br /> 1 -Size <br /> , : � <br /> ` EEPAGE PITS i Depth ; ` . Number . <br /> SUMPS t X i Distance to nearest: Wel l/9VJ2�oundation Property Line _ <br /> D PO 9L-,PONDS <br /> ISPO i( <br /> application and that the work will be done in accordance with'San Joaquin county <br /> i 1 hereby certify that I.lihave prepared this app ; <br /> ordinances, state laws,.,and rules and regulations of the San Joaquin Local Health District: t- 1erfb�mance of . <br /> Home owner or licensed agent's signature certifies <br /> suchFinannernas to becomeysubjectthat ntohwoprkman s campensatianwlawsfof California." <br /> permit is issued, I shall not employ any p <br /> Contractor's hiring or sub-contracting signature certifies the following: "1'certify"that in the performance4of the�work €or_whi f'r'e <br /> this permit is issued, I s 11 employ persons subject to workman:` compensation laws..of Cal-ifornia." .-Y__-_------s <br /> The applicant must <br /> ca if <br /> all req r inspections. Complete dra ing reve a side. <br /> *; M Date <br /> Signed X Title: <br /> OR DEPARTMENT USE ONLY 5tk �4'6fi;6781'.; ' 1 <br /> Application Accepted by <br /> Area <br /> Ad t" . . k3 . - Lodi 1�,-369-3621' 9 <br /> AddatianalG&mments: Date w =x ; Manteca 823-7104 <br /> i <br /> �'N•Pit cs-s rotyt Inspection by Tracy X835-6385 . C3 <br /> , ' { <br /> Final Inspectiorii 6y s�- e. ..,, Date "" <br /> Applicant � Return all copies ' :.Environmental Health Permit/Services 1601 E. Hazel tan Ae�a�P.Ofx 2009-, 5 •! CA <br /> 95201a r <br /> +a <br /> }� PERMIT N0. <br /> FEE BASE �� AMOUNT iIUE_- �_. MA OUNT REMITTED "RECEIVED-BY <br /> DA; >1.'[/ <br /> INFO I� �- -�• = Y.?s? ��i_y �. �I_ _ <br /> "..+"-- " •--- —'"�.-......M ,,:�s�=. .rte.- - ^��* .. <br /> --T--• R S_ � ''; _ �sa. ,]. -�—I0/82-500r...d.­ <br /> [ £H 13-24 <br /> 14-26 II <br />