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APPLICATION FOR PERMIT <br />` SAN JOAQU,N LOCAL HEALTH viS..ICT .Q L.�_30q <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0.QQ [[ <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <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 /> i and the Rules and Regulation of the San Joaquin Local Health District. <br /> Jab Address Subdivision Name <br /> Owner's NamANarne <br /> te ddress �� � <br /> Contractor' A-", ,icense No, Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR L3 OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE ' <br /> FOUNDATION <br /> AGRICULTURE WELL OT ER WELL PITS/SUMPS <br /> INTENDED USE' —TYPEIOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i !] Industrial LJ Open Bottom Manteca DiaJ;of Well Excavation <br /> lJ Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public Other Delta /Type of Casing <br /> Irrigation Approx. Eastern s r' Specifi:catJons_ � <br /> E <br /> Cathodic Protection Depth Depth of Grout Seal <br /> ` Geophysical ' Type of Grout i <br /> U Other '* d Surface Seal Installed by <br /> H,P, State Work Done <br /> Repair Work Done .[j Type of Pump i <br /> Well Diameter Sealing Material (top 55Q.') <br /> Well Destruction U ti <br /> -➢epth` it I er�Materigl­(Below 50') lJ <br /> TYPE OF SEPTIC WORK. NEWiINSTALLATION L1 REPAIR/ADDITION (No septitttank-urzsEepage-pi'availableewithinn 200csewerfeet.) is, <br /> n �!Installation will serve: Residence Commerciale Other <br /> i � Lot size _. �-� f <br /> k Number of living units: / Number of bedrooms �c__ _ 6, <br /> Character of soil to a depth of 3rfeet;. SL1 <br /> - Water tahl e;depth <br /> Ii SEPTIC TANK �f Type/Mf9 Capacity No. Compartments <br /> [ _ Capacity J Method of Disposal <br /> f PKG, TREATMENT PLT. F] Type/MMfg� _ -- <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. &.Length of lines Notal length/size <br /> FILTER BED Distance to nearest:' Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depthl ?� Size �- r� Number <br /> SUMPS Distance to nearest: Well 1 o a Foundation l d Property Line S� <br /> DISPOSAL PONDS <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 ]oaquin.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 /> P is issued, I shall not employ any person in such manner as to become subject to workmans 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 /> k <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant st call for all '.red inspections. Complete drawing on reverse side. �' <br /> Signed X <br /> Title: //f i'-_ • Date: <br /> F R DEPARTMENT US NLY Stk 466-6781 <br /> Application Accepted by Area �� <br /> � <br /> =Lodi 369-3621 <br /> Additional Comments: Manteca 823-7104 <br /> Pit or Grout Inspection by Date <br /> Date ❑ Tracy 835-6385 <br /> Final Inspection by <br /> Applicant - Return all copieo: Environ s tment Healtrmit/Services 1601 F. Hazelton Ave., P.O. Bax 2009, .Stk., CA 45201 <br /> PERMIT N0. <br /> FEE BASE AMOUNT DUE _AMOUNT REMITTED RECEIVED BY zDATE L� � <br /> INFO 0 3-a3-�3 I <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-25 <br />