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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �[ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. V3-?q 1 <br /> Telephone (209) 466-6781 <br /> DATE ISSUED K-11 -Y3 <br /> _11 -Y3 <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. JOA <br /> ,�A,.0, � <br /> Job Address � Z8Z5' Subdivision Name� �1)�'�, fA-)I � <br /> �'✓�`J.d3�- <br /> Owner's Name Lo,T Address SA&a Phone <br /> Contractor's Name'JP G ANS License No. 2,ZLJ 2 Phoney- <br /> 9 <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER �J <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 /> F-1 Industrial U Open Bottom F� Manteca Dia. of Well Excavation <br /> bomestic/Private, F Gravel Pack F] Tracy Dia. of Well Casing <br /> Public F-1 Other Delta Type of Casing <br /> Lj Irrigation Approx. Eastern <br /> Depth Specifications <br /> F-1CathodicProtection Depth of Grout Seal <br /> 1-1 Geophysical Type of Grout <br /> LJ Other <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <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 J< .(No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residenc e Commercial _ Other <br /> Number of living units: -/— Number of bedrooms _ Lot size <br /> Character of soil to a depth of 3 feet: Water table depth br <br /> SEPTIC TANK ❑ Type/Mfg Capacity — T No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE' SYSTEMDistance to nearest: Well Foundation Property Line <br /> DESTRUCTION E] k <br /> LEACHING LINE No. & Length of lines -20 " Total length/size �Q u <br /> FILTER RED h -Distance to nearest: Well Foundation _ Property Line <br /> Q <br /> SEEPAGE PITS [j Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D r <br /> v <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 hi g or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit i i s d, I shal employ p sons ubject to workman's compensation laws of California." <br /> The applic m 11 fo 11 re cti ns. Comple a dr �.'n on reverse side. <br /> Signed X Title: Date: (�( <br /> FOR TMENT USE ONLY <br /> Application Accepted byr Area Lo 7 <br /> E] Stk 466-6781 \ <br /> Additional Comments: E] Lodi 369-3621 <br /> Pit or Grout Inspection by oeDate Manteca 823-7104 <br /> Final Inspection by _ � +�/ Date Tracy 835-6385 <br /> Applicant - Return all copies to:- EnvirorMterttal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82. _ <br /> 10/82 500. <br /> 14-26 <br />