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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH, DISTRICT PERMIT N0. ,q 4 I3 <br /> I 1601 E. HAZELTON AVE., STOCKTON, CA �iQ <br /> Telephone (209) 465-6781 DATE ISSUED <br /> R <br /> PERMIT EXPIRES 1 <br /> YEAR FROM M DATE ISSUED <br /> (Complete in Triplicate) <br /> i <br /> Application is hereby made to the San"Joaquih Local Health District for a permit to construct and/or install the work herein <br /> ance No. 549 for sewage or No. 1862 for well/pump <br /> described. Ihis application is made in compliance with San Joaquin County Ordin <br /> and the Rules and Regulationslof the San Joaquin LocalhealthHealth District. <br /> a�H_i Subdivision Name <br /> Sob Address �7 <br /> Address Phone <br /> Owner's Name Phone <br /> Contractor's Name License Na. <br /> rlJV <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION <br /> fff PUMP INSTALLATION SYSTEM REPAIR OTHER E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD, PROP. LINE � <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS n 1 <br /> INTENDED USE TY',[ OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Fj industrial U Open Bottom ElManteca <br /> Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack [J Tracy Dia. of Well Casing <br /> Public F-1 Other Delta Type of Casing <br /> Lf Irrigation Approx. Eastern Specifications <br /> ❑ Cathodic Protection Depth Depth of Grout Seal <br /> Geophysical Type of Grout <br /> U Other Surface Seal Installed by pd <br /> ' H.P. State Work Done <br /> Repair Work Done EJ Type of Pump <br /> Well Destruction U Well Diameter Sealing Material (top 5O') <br /> 3 Depth 1 . Filler Material (Below 501 <br /> '+ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION �� -� available within 200 feet.) <br /> i <br /> Installation will serve: Residence _ Commercial Other <br /> Number of bedrooms Lot size <br /> f Number of living units: Water table depth <br /> Character of soil to a depth o,f 3 feet: No. Compartments <br /> F-1SEPTIC TANK Type/Mfg Capacity <br /> } Capacity Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Type/�f9 Propert Line <br /> SEWAGE SYSTEM. Dista Ice to nearest: Well Foundation y <br /> DESTRUCTION <br /> No.' &FLen th of lines Total length/size <br /> LEACHING LINE LJ 9 Property Line <br /> FILLER BED FlDistance# to nearest: Well Foundation <br /> DeptSize Number <br /> SEEPAGE PITS ❑ De p Property Line <br /> SUMPS U Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ I <br /> I hereby certify that 1 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 /> rformance Home owner or licensed agent's signature cersvn1en suchfman�ernas to becomeg- 111 ysubjectthat ntohworkman, compersatlionwlawsfof California." <br /> permit is issued, I sha11 not employ any p <br /> Contractor's hiring or sub-contracting sinature certifies <br /> to workman�sl�ompensationrlaws ofaCalifornia�rformance of the work for which <br /> this permit is issued, 1 shall employ persons <br /> The applicant mQ5.t 11 or all r uired inspections. Complete drawing r erse rn Date: <br /> � Title: <br /> Signed X <br /> ARTMENT AE ONLY f Area Stk 466-6781 <br /> — ► __. <br /> Application Accepted byl Lodi 369-3621 <br /> Additional Comments: '- Date Manteca 823-7104 <br /> Pit or Grout Inspection by Tracy 835-6385 <br /> Final Inspection by _f. r <br /> Date 4�lt'n <br /> Applicant - Return all copies to: Environmental Health Permit/Services 160 EAve., P.O. Box 2009, Stk., CA 95201 <br /> DATE PERMIT NO. <br /> FEE BASE AMOUNT E <br /> AMOUNT REMITTED RECEIVED BY <br /> INFO � ��DUp <br /> I <br /> 10182 500 <br /> I EH 13-24 REV. 10/82 <br /> 14-26 <br />