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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �J �,—�-- <br /> Telephone (209) 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 Local Health District. <br /> Sob Address ��2�-tG �'� Subdivision Name <br /> Owner's Name e!?2&C,�CLtp ���'f 7f � Address Phone <br /> Contractor's Name IMLLE�/ M f <br /> G , License.No. 3 31 !� phone } rtt�3i <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> ` PUMP INSTALLATION F-1 SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I <br /> INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial [f Open Bottom [] Manteca Dia. of Well Excavation <br /> LJ Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well Casing <br /> Public F-1 Other 0 Delta Type of Casing F <br /> LjIrrigation Approx. Eastern Specifications <br /> ❑Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical Type of Grout <br /> [J Other Surface Seal Installed by ,C <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done �] <br /> Well Destruction [_1, Well Diameter Sealing Material (top 501) — <br /> Depth Filler Material (Below 50') 1i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pitpermitted ifpublic <br /> thin 200fseter isavailable ~ <br /> Installation will serve: Residence _ Commercial Other ` <br /> Number of living units: Number of bedrooms Lot size <br /> 4 <br /> y , Water table depth <br /> Character of soil to a depth of 3 feet: �..�- _ <br /> SEPTIC TANK ) Type/Mfg �(�'F- ST `t'aG f�� Capacity 6bpi+ 6441 No. Compartments <br /> od of Disposal <br /> PKG. TREATMENT PLT. ❑ Type/Mfg ' Capacity Meth <br /> SEWAGE SYSTEM' Distance to nearest: Well _1316` Foundation O' Property Line ° <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines Total length/size - C <br /> FILTER BED Distance to nearest: Well Foundation Property Line c� <br /> SEEPAGE PITS YJ Depth __.f Size " Number <br /> SUMPS ElDistance to nearest: Well le Foundation $�P Property Line <br /> DISPOSAL PONDS ED <br /> f <br /> I hereby certify that 1 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 hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> ject to workman's compensation laws of California." <br /> this permit is issued, I shall employ persons sub <br /> The applicant ust call_for all rwired inspections. Complete draw, n reverse side. 3 <br /> Signed X <br /> G/,�: Title: 44fJ Date: <br /> 4Fnvironmertal <br /> ART Area �� Stk 466-6781 <br /> Application Accepted by <br /> Lodi 369-3621 <br /> Additional Comments- C� Manteca 823-7104 <br /> Pit or Grout Inspection b Date <br />'f Final Irspection by <br /> Date � ❑ Tracy 835-6385 <br /> r <br /> Applicant - Return all copies o: 201 <br /> health Permit/Services 1661 ze ton Ave., P.O. Box 2009, Stk., CA 95 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE <br /> PERMIT NO. <br /> INFO 7.3 <br /> .r <br /> _S <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 ' <br /> 14-26 ' <br />