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a f <br /> e ..—� `� '�`: —• +INS ._maw <br /> a APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 71 <br /> Telephone (209)466-6781 <br /> ` DATE ISSUED Il �f <br /> PERMIT EXPIRES '1 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 Local'Health District. �- <br /> Job Address 1A ZZ AV, [ Subdivision Name <br /> Owner's Name Address <br /> Phone p� <br /> Contractor's Name ;y License No. Phoneme <br /> I <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ 6 <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER EJ <br /> DISTANCE TO NEAREST: SEPTIC TANK .I SEWER LINES DISPOSAL FLD. PROP. LINE iA <br /> !� FOUNDATION '',I AGRICULTURE WELL OTHER WELL �W PITS/SUMPS - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSS <br /> I Industrial ❑Open. Bottom 0 Manteca Dia, of Well Excavation <br /> Domestic/Private r ` <br /> (.� �Gravel Pack Tracy Dia, of Well Casing <br /> 1 Public " <br /> f� E � Other � Delta , <br /> _ i <br /> L_} <br /> irrigation Type of-,Casing 9 Approx. Q Eastern �, r . <br /> Cathodic Protection Depth + - Specifications' _ Y <br /> D pth of Grout Seal "'M <br /> Geophysical — es <br /> Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done EJ Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION No septic tank or see <br /> s ' �' ( p page pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence commercial _ Other <br /> Number of living units: Number of bedrooms .3 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 nn <br /> Distance=to nearest: Well Foundation Property Line C - <br /> LEACHING LINE No, & Length of lines 2 <br /> 9 Total length/size p <br /> FILTER BED ❑ Distancelto nearest: Well Foundation yip Property Line <br /> SEEPAGE PITS Depth _ Size i . Number T_ <br /> SUMPS U Distance to nearest: -Well�38 , Foundation moa= ` Property Line�O _ <br /> DISPOSAL PONDS ' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. San Joaquin county <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 shallnot employ any person in such manner as to become subject to workman§compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant must call for all r wired i ction Complete draw;A on leverse sid <br /> Signed X Title: Date: / <br /> FOR MW MENT USE ONLY <br /> Application Accepted ,e -11—i3.�z Area Stk 466-6781 <br /> Additional (j' <br /> Comments: t,r <br /> Lodi 369-3621 <br /> Pit or Grout Inspection b Date <br /> Manteca 823-7104 <br /> Final Inspection by Q �EHazel7an <br /> lft Tracy 835-6385 <br /> Applicant - Return all copi to: Environmental Hea h Permit/Serv- Ave„ P.O. Box 2009, Stk., CA 95201 , <br /> i <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, <br /> INFO <br /> EN 13-24 REV. 10/82 <br /> 14-26 10/82 500 <br />