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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT PERMIT NO. r:S _ �;t-» <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 456-6781 DATE ISSUED <br /> PERMIT EXPIRES 1,YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> rein <br /> Applicatibn is hereb madeonoishe Sande iJoaquin Locelw Health <br /> ith DJoaquin County p0 dinanceernit'to cNo5t549tfordsewagesorlNoth1862rforewell/pump <br /> istric <br /> described. This app <br /> and the Rules and Regulations of <br /> of tthe San Joaquin Local Health District. <br /> Job Address <br /> D Jr/YDd�T C-114> subdivision Name Phone �/ !—_2 <br /> Owner's Name 44 <br /> � a Address Phone <br /> L-icense Na. <br /> Contractor's Name a <br /> WELL REPLACEMENT ❑ DESTRUCTION <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ OTHER ❑ �,} <br /> PUMP.INSTALLATION ❑ -SYSTEM REPAIR {] I <br /> DISPOSAL FLOPROP. LINE ` <br /> SEWER LINES PITS/SUMPS. _ <br /> DISTANCE TO 'NEAREST: SEPTIC TANK �_� AGRICULTURE WELL �_,_� OTHER WELL <br /> FOUNDATION <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA 6 <br /> Open Bottom ❑Manteca Dia. of Well Excavation <br /> Industrial Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑Tracy <br /> ❑ Public ❑Other ❑ Delta Type of Casing <br /> j ❑ Irrigation Approx. ❑ Eastern Specifications <br /> E]Cathodic Protection <br /> Depth Depth of Grout Seal <br /> - <br /> ❑Geophysical Type of Grout <br /> ❑Other Surface Seal Installed by <br /> State Work Done <br /> of Pump _�_�_ <br /> Repair Work Done ❑ -Type SeH.P - — <br /> Well Destruction F-1WellDiameter <br /> Sealing Material (top 50') <br /> f Filler Material (Below 50') <br /> Depth <br /> No septic tank or seepage pit permitted if public sewer is <br /> REPAIR/,ADDITION J ( available within 240 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ <br /> Commercial Other j <br /> Installation will serve: Residence — Co — Lot size � VNumber of living units: Number of bedrooms Water table depth <br /> kSCharacter of soil to a depth of 3 feet: Capacity ��_ No. Compartments <br /> ' SEPTIC TANK ❑ Type/Mfg Capacity _�� Method of Disposal <br /> r PKG. TREATMENT PLT. ❑ Type/Mfg Foundation Property Line <br /> Ik SEWAGE SYSTEM ❑ Distance to nearest: Well <br /> i DESTRUCTION Total length/size <br /> LEACHING LINENo. & Length of lines <br /> �--� Foundation Property Line <br /> I FILTER BED ❑ Distance to nearest: Well <br /> Size Number <br /> SEEPAGE PITS ❑ Depth �� Foundation — Property Line <br /> SUMPS Distance to nearest: Well <br /> DISPOSAL PONDS ❑ s60— i^ <br /> ` I hereby certify that I have <br /> ruprepared <br /> d this <br /> applica i n and <br /> that <br /> the <br /> work <br /> oocalwill <br /> be done <br /> istrnctccordance with San Joaquin county <br /> ordinances,,state laws, that in the performance of the work for which this <br /> Home owner or licensed agent's signature certifies the following: "I certify <br /> permit is issued, 1 shall not employ any person in such manner as to become subject to workman compensation laws of California. <br /> Contractor's hiring or sub-contra Jay <br /> signature certifies <br /> the <br /> to following: "I <br /> certify <br /> ation laws than n tof rnihe aerformance of the work for which <br /> this permit is issued, I shall p Y persons <br /> The applicant ust ca 1 for all re uired• inspections. Complete drawing on reverse side. Date: <br /> � �Jj Title: <br /> Signed X �tk 466-6781 <br /> �� Fp ARTMENT USE ONLY — Area —AV-13 _ u <br /> Application Accepted by y ❑ Lodi 369-3621 <br /> F Additional Comments: Date ��— ❑ Manteca 823-7104 <br /> Pit or Grout Inspection by Date jU��8 _ ❑ Tracy 835-6385 <br /> Final Inspection by <br /> Applicant - Return all cop' o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, St k., CA 952D1 <br /> AMOUNT REMITTED RECEIVED BY <br /> DATE PERMIT N0. <br /> FEE BASE AMOUNT DUE <br /> INFO 3 Ob <br /> 1 O J 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />