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f <br /> G - <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 13 157 <br /> f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. g3— 1 <br /> Telephone (209) 466-6781 <br /> DATE ISSUED 10—L4 $j <br /> PERMIT EXPIRES 1 YEAR, FROM DATE ISSUED <br /> t� (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 (yJ W <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/Pump t i <br /> and the Rules and Regulations o -the San Joaquin Local Health District. — O <br /> Job Addres Q0 g . r Subdivision Name �SC,y�-/_p�/ ���� _ _ a <br /> Owner's Name ,;ae ddress Phone 5 <br /> . 2Y-�//23 �. ., <br /> Contractor's NameZAI License No. <br /> TYPE OF WELL/PUMP WORK: NEW141ELL WELL REPLACEMENT DESTRUCTION U <br /> " PUMP INSTALLATION �- SYSTEM REPAIR OTHER [_JDISTANCE TO NEAREST: SEPTIC TANK/ SEWER LINES DISPOSAL FLD PROP. LINE <br /> FOUNDATION / AGRICULTURE WELL/ J-- -Q__ OTHER WELL I_rtS­_Q_ PITS/SUMPS <br /> INTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 9' <br /> Industrial U Open'Bottom Manteca Dia. of Well Excavation <br /> mestic/Private Gravel Pack Ej Tracy Dia. of Well Casing <br /> IPublic Other. ❑Delta Type of Casing � 1� <br /> ❑ Irrigation Approx. Eastern Specifications 1 I <br /> Cathodic Protection Depth <br /> Depth of Grout Sea <br /> Geophysical - <br /> U <br /> _a Other <br /> Type_of_Gra at_._ _ QA/ � <br /> Surface Seal Installed by R + I✓'C,t <br /> Repair Work Done ❑ Type of Pumpc5�4/k L. H.P. l State Wor4 Done <br /> Well Destruction ❑ Well Diamef�er1 �� f Sealing Material (top 50'} <br /> Depth ( Filler Material)(Below 50'.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/,ADDITION Lf (No septic tank or seepage pit permitted if public sewer :is <br /> „ _�.;.,_a.va-i-1 able within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth.off3 feet: Water table depth �I <br /> y SEPTIC TANK ❑ Type/Mfg y Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ <br /> LEACHING LINE ^- LI No. & Length of lines Total length/size <br /> FILTER BED •-J Distance-.toinearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS L-1 Distancelto nearest: Well Foundation Property Line <br /> DISPOSAL PONDS CI <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's compensatian 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 /> permit is issued, I shall persons subject to workman's compensation laws of,,California." <br /> The licant must call for 1 re it gins e=ons. Complete drawing on reverse side.' <br /> Si n Title: ( 1� (1/U1 - _ Date: C) ' <br /> R DEPA T US NLY <br /> Appl cation Accepted by Area Stk 466-6781 <br /> Ad 'tional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by LAn Date Manteca 823-7104 <br /> Final Inspection by Date �� }'j Q! L7 Tracy 835-6385 <br /> " Applicant - Return all copies to: Environmen al Health Permit/Services 1601 E. Hazelton ve., P.O. box 2009, Stk., CA 95201 <br /> FEEBASE AMOUNT DUE AMOUNT'REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 ' REV: 10/82 <br /> �jA 10/82 500 <br /> �d /r ��C� <br /> 14-26 _ <br /> a5 � <br />