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F APPLICATION FOR PEKiilT <br /> SAN JOAQ611'� LOCAL HE�.LTH DISTRICT <br /> 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 13 � I <br /> ' Telephone (209) 466"-6781 - <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> ipft� <br /> (Complete in Triplicate) <br /> A <br /> ' Application is hereby made to the Sari 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 Re ul tion of the San Joaquin Local Health District. <br /> Job Addressle,_! �- Xi�T��_ TbL/� Subdivision Name <br /> r <br /> Owner's Name �"--" -` Address1� }+ 7_SrrLT0 � 155i&A Phone <br /> ( Contractor's Name License No. M257WS Phone <br /> I <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U <br /> f PUMP INSTALLATION SYSTEM REPAIR OTHER U UJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> L7 Public Cl Other Delta Type of Casing <br /> L, Irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> ❑Geophysical <br /> Type of Grout <br /> U Other Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done W <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> k r 't , +•4 f I available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of hiving units: 4- Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg + Capacity Method of Disposal <br /> SEWAGE.SYSTEM Distance to-.n rest: Well foundation Property Liner — <br /> DESTRUCTION t rny <br /> LEACHING LINE U No. &1Lengthyof'lines " �tr. Total length/size <br /> FILTER BED Distance-to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depths i Size ` Number t <br /> SUMPSt Distance' to nearest: Well ( T .}Foundation Property Line <br /> r DISPOSAL PONDS �," { •. <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 the San Joaquin ;Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued, I shall not employ any-person_in.such-manner-as to,become subject to workman compensation laws of California." <br /> Contractor's ring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit issued, I shall e oy persons subject to workman's ompensation laws of California." <br /> The applica 11 for all quir inspections. Co ng on reverse side. <br /> Signed X V. <br /> Title: ��f Date: <br /> FO EPA ENT USE ONLY <br /> Application Accepted by � `� Area / Stk 66-6 8 <br /> I Additional Comments: k Lodi 369-3621 <br /> Pit or Grout Inspection by"' Date Manteca $23-7104 <br /> r <br /> Final Inspection byEZ Date y ❑ Tracy 835-6385 <br /> Applicant 7Retr,�,,, to Env" o ntal Health P i Services 1601 E, yazel Rve. P.O. Eox 2009, Stk., CA 95201 <br /> FEEAMOUNTI DUE .AMOUNT REMITTED , RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> I EH 13-24 REV. 10/82 ; 10/82 500 <br /> k 14-26 <br />