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r s <br />54 <br />APPLICATION'FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO._ <br />Telephone (209) 466-6781 <br />DATE ISSUED, O o2 6 Y <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 j <br />described. This application is made in compliance with Sah Joaquin County Ordinance No. 549. for sewage or No. 1862 for well/pump <br />and the Rules and R ulati ns of the San Jo quin Local Health.District. <br />Job Address Z, Subdivision Name <br />Owner's Name ' 1yy/ S Address _ ` L gyicv p _Phone <br />Contractor's Name )_Ei=. w'&I_ License No. Phone Ote, <br />TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT E] DESTRUCTION <br />PUMP INSTALLATION [] SYSTEM REPAIR OTHER i <br />r_ _ _... DiSTANCf T0"NEAREST 'SEPTIC`TANK SfWfR'CINES'-" DISP0 5AL FLD. 15ROP "LINE 7"" <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />F1 Industrial u Open Bottom [ Manteca Dia. of Well Excavation <br />r <br />f Domestic/Private F-1 Gravel Pack Tracy Dia. of Well Casing <br />Public 'Other Delta Type <br />j F-1 Irrigation Approx. [] Eastern Specifications <br />E3 Cathodic Protection Depth <br />Depth of Grout Seal <br />Geophysical <br />Type of Grout <br />Other <br />Surface Seal Installed by <br />WorkRepairWorkDoneTypeofPumH.P. State DonePYPP <br />Well Destruction U Well Diameter Sealing Material (top 50') ` 1 <br />Depth Filler' Material (Below 501) ; <br />TYPE OF SEPTIC WORK:' NEW INSTALLATION-U—REPA•IR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br />j available within 200 feet.) pp <br />Installation will serve: Residence Commercia Other <br />Number of living units: <br />T <br />Number of bedrooms _ Lot size <br />3 <br />Character of soil to adepth of 3 feet: r)% __ Water table depth <br />SEPTIC TANK Cji_. Type/Mfg Capaci-ty No. Compartments <br />PKG. TREATMENT PLT. . Type/Mfg Capacity Method of Disposal <br />h j Distance to nearest: Well oundation Property Line <br />LEACHING LINE , f No..&..Length,oflines Total length/size <br />I <br />FILTER <br />BEDf <br />Y <br />Distance to nearest: Well Foundation Property Line <br />SEEPAGE.PITS Depth _. ( Size 3 Dumber <br />SUMPS Distance'to'nearest: Well Foundation Property Line <br />DISPOSAL PONDS <br />6 <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 lawsr, 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 />Contractors 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 />ica t must cal for all r ired i pections. Complete drr ing o rse e. <br />S Title: f ']/ ,f <br />s <br />Date: <br />F r03—. <br />F DEPART 9 -T USE ONLY <br />Application Accepted by r-r,r<<rt., Area Vie. Stk 466-6781 <br />Additional Comments Q,,ef-44-7,0 4Z /G zY Lodi 369-3621 <br />Pit or Grout Inspction b Date — Q Manteca..823-7104 <br />Final Inspection by <br />v <br />Ad DatTracy 835-6385 <br />Applicant - Return all copies to: Environmental 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 />f <br />f <br />EH 13-24 REV. 10/82 1O/B2 500 <br />14-26