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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 7 <br /> Telephone (209) 466-6781 ` DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �"- <br /> (Complete in Triplicate) <br /> Application is hereby made to the Sar. 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 andRegulations of the San Joaquin L cal Health District. Y J <br /> 0." Subdivision Name ' <br /> Job Address�� �"JZ4 ` <br /> Owner's Name <br /> Address Phone <br /> Contractor's Ny <br /> License No. Phone '`J37— ��fr� <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [] DESTRUCTION CLE/ R s <br /> PUMP INSTALLATION �- SYSTEM REoAIR ❑ OTHER ❑ , <br /> DISTANCE TO NEAREST: SEPTIC TANK fes• -- SEWERI1INES r DISPOSAL FLO. t�PROP. LINE / <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f <br /> r <br /> I a f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial pen Bottom ❑Manteca Dia. of Well Excavation <br /> stic/Private F-1 Gravel Pack ❑Tracy Dia. of Well Casing <br /> Public ❑Other Delta <br /> ❑ Types of Casing + <br /> LjIrrigation Approx. ❑Eastern Specifications <br /> ❑ ¢ t <br /> I Cathodic Protection Depth - �- <br /> i� Depth of Grout Seal <br /> ❑Geophysical ��"` Type of Grout .1 , <br /> LJ Other f <br /> � Surface Seal Installed by --- <br /> 4 State 7fineRepair Work Done [_j Type of Pimp H.P. Y"rSealin Mat2rial (top 50')We11 Destruction Well Dihmeter _� 9 Depth � Filler Material (Below 50') 1 . <br /> Ik � <br /> TYPE OF SEPTIC WORK: NEW,INSTALLATTON ❑1 REPAIR/ADDITION 1J (No septic tank or seepage <br /> pit permitted <br /> withinu200�feete) is i 1. <br /> Installation will serve: Residence _ Connercial _ Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> ` SEPTIC TANK ❑, Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Type/Mfg Capacity Method ne Disposal <br /> SEWAGE SYSTEM-. Distance_to nearest:_Well. foundatton,^ _ Property Line <br /> CESTROCTION 'I Q .r k - <br /> �- No. &'Len th-of 1•• <br /> ines '3�--Total=length/Size — <br /> { LEACHIrN� LINE- 9 '" - <br /> FILTER BED! ❑ Distance to nearest: Well Foundation Property Line <br /> - Size Number <br /> SEE4AGE PITS ❑ Depth <br /> SUMPS- ❑ Distance to nearest: Well — Foundation _ Property Line <br /> DISPOSAL PONDS ❑ <br /> l�hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> y drdinances, state laws, and rules and regulations of the San Joaquin Local Health District_ <br /> i'Iti•Home owner or licensed agent's signature certifies the followi <br /> mannernas to become suhjectthat ntohwopkman compensationof the wnce <br /> lawsfof California." <br /> permit is issued, i shall not employ any p performance of the work for which a <br /> ` I Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the a. <br /> / this permit is issued, I shall loy persons subject to workman's compensation laws of California." <br /> �he applic nt t call for a equir inspections. Complete dr ng on r verse side. Date: <br /> ( i Signed X _ Title: <br /> al—A <br /> f FOR DEP RTMENT USE ONLY n Stk 466-6781 <br /> A lication Accepted by — Area <br /> Lodi 369-3621 <br /> Additional Comments: Dat Manteca 823-7104 <br /> Pit or Grout Inspection Dat <br /> Final Inspection by — <br /> Date Tracy 835-6385 <br /> Applicant - Return all copi nvironmer.tal Health Permit/Services 160 E. azelton Avl', P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0.b^ ONO <br /> ` INFO ` ']-_7�5-76 <br /> 10/82 500 � <br /> EH 13-24 REV. 10/82 <br /> 14-Zb Y <br />