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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3— <br /> Telephone (209) 466-6781 DATE ISSUED f ur <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 nd Regulations o he'Sd0 Joaquin Local Health District. <br /> Job Address Er2 Subdivision Name <br /> Owner's Nam r Address Phone <br /> Contractor's Name -F �11��#\L License No, �r,ZQ Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT .DESTRUCTION o <br /> PUMP INSTALLATION SYSTEM REPAIR" POTHER" <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _�j. 3 DISC P� 05AL FLD. PROPw LANE <br /> t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I] Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> IJ Domestic/Private Gravel;Pack TracyDia, of Well Casing <br /> Public EJ Other j [] Delta <br /> Type of Casing - - <br /> Irrigation Approx. ] Eastern <br /> De th Specifications <br /> F-ICathodic Protection {p Depth of Grout Seal <br /> Geophysical Type of Grout W ' <br /> U Other , Surface.ISeal Installed by <br /> Repair Work Done ❑ Type of Pump_ . H.P. State Work Done i <br /> c <br /> Well Destruction ❑ Well Diameter t Sealing Material (top 50') t _ <br /> Depth Filler Material (Below 50') r + <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONS REPAIR/ADDITION U (No septic tank-or seepage pitavailable <br /> if public sewer is <br /> { 1 available within 200 feet,} 3 : <br /> Installation will serve: Residence Commercial._ Other t <br /> Number of living units: Number of bedrooms L15t`siie f ! <br /> I € # <br /> Character of soil to a depth of;3 feet: Water table depth p <br /> SEPTIC TANK Type/Mfg (;il`> _ Capacity No. Compartments <br /> # Ca acit '_ ""``"' 11" thod`of'USsposal��I" y <br /> PKC. TREATMENT PLT. � Type%Mfg - P y f <br /> SEWAGE SYSTEM Distance tolnearest: Well Foundation. Property Line <br /> DESTRUCTION ', t <br /> LEACHING LINE No. & Length of lines - ri~ = + Total length/size , <br /> FILTER BED Distance tolnearest: Well9 (�('� Foundation Property Line ; <br /> SEEPAGE PITS Depth i 5 Size INumber <br /> SUMPS Distance to nearest. Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have .prepar,ed this application and that the w6rk 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 mariner 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 /> ermit is issued, hall empl persons subject to workman's,compensation{laws of California." <br /> The lican all fo red- _ .,p.. ions. Complete d ing'on-r verse i <br /> Signe Title: Date: I <br /> 1 FOR. D ART T USE DAILY <br /> Application Accepted by (ti Area 0 s' [ Stk 466-6781 <br /> Additional Comments: t f c c '�� [] Lodi 369-3621 <br /> Pit or -Grout'Inspection b Date l— 3 LEI Manteca 823-7104 i <br /> Final.Inspection by % Oate .w/�- P1 L Tracy 835-6385 <br /> Applicant - Return all copies to: Enrvi rronmen,ta.l�Health-P,e.rmi:t/,Ser-vices Y601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> s , <br /> ��FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> ,..� _EH... 1�--,--3-24 R'EV:'I0]82` -1! "�....,� �.ja�.. ,- ,.,, . ... 1 82 500 <br /> -� <br /> 14-26 <br />