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I <br /> APPLICATION FOR PERMIT <br /> SAN ]OAQUiN LOCAL HEALTH DISTRICT ! <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. '93 - /,-Lb ' <br /> Telephone (204) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES I.YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) { <br /> Application is hereby made to the'San 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 Regulations of the San Joaquin LocalHealthDistrict. <br /> Job Address �Sj2 . J� JS 01-00. <br /> Subdivision Name <br /> Owner's Name J / Address Phone f,;13 -3&0'> <br /> &0'> <br /> Contractor's Name / License No, ZY43.0tLt Phonew4-04-07 <br /> TYPE OF WELL/PUMA WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER� LINES DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION + AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USETYPE OFWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom [] Manteca Dia. of Well Excavation �3 <br /> LJ Domestic/Private Gravel Pack [] Tracy Dia. of Well Casing l <br /> —r"... <br /> Public f-1 Other Delta Type of Casing <br /> I^i Irrigation Approx. E] Eastern <br /> [Cathodic Protection Depth1-1 Specifications <br /> k , Depth of Grout Seal <br /> Geophysical Type of Grout <br /> U Other {{s Surface Seal Installed by <br /> Repair Work Done �J Type of Pump f H.P. State Work Done <br /> Well Destruction L Well Diameter . � Sealirk Material (top 50') <br /> Depth FillerMaterial (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION X(No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.-) <br /> Installation will serve: Residence Commercial — Other <br /> Number of living units: _ _L Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water_table�depth <br /> SEPTIC TANKlie Type/Mfg Capacity /��C �.No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg I i Capacity � rMe'thod of Disposal <br /> SEWAGE SYSTEM 16 Distance to nearest: Well . �,�'�­Foundatio r Property Line <br /> —" KDESTRUCTI4N t ! <br /> LFACHING LINE.J,� U N0.*& Length of lines Total length/size <br /> FILTER BED Q f Dittance to nearest; Well's Foundation ;Property Line <br /> SEEPAGE PITS Depth size., Number <br /> SUMPS Distance to'nearest: Wel l"� Foundation Property" Line ! <br /> 01SP05A'L PONDS 1y <br /> 3 v �t . <br /> I hereby�cer"tafy .that sI;ha've 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 hi ing or, sub-contracting signature certifies the`foll'owing': "I certify that in the performance of the work for which <br /> this permit i s ed, I shall employ rsons jec to workman's compensation laws of California." <br /> The appli a fo 11 re ed p inns Compl i g on reverse,side. <br /> Signed X Date: 4 <br /> T USE RR ONLY <br /> Application Accepted by:����FO <br /> Area �� ZX'Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection Date Manteca 823-7104 <br /> Final Inspection by' '� p/rr�� Date/O; L Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 45201 <br /> -FEE BASE -AMOUNT DUES AMOUNT REMITTED" RECEIVED BY DATE PERMIT N0. <br /> b.._-'...�..,.,..._.. — 7�— <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />