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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> PERMIT NO, j 3—�� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781. DATE ISSUED -7-ft <br /> PERMIT <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> rein Oq <br /> an <br /> Application is hereby <br /> }cadeonoishmadeniecomplia�celwlithlSanDistrict <br /> Joaquin Countypermit <br /> 0 dinancecNo, 549tfor dsewage sorlNo. 1962rfor ewel}/pump <br /> described. This app 1 <br /> and the Rules and Regulations of tp son Joaquin c11 Health District, <br /> S_ ��� �+id d�ivision Name. <br /> Job Address Phone <br /> �. <br /> ' Rddressr'(5 � a 1� 1l �� ray <br /> Owner's Name .0. V R i Phoneme 1 <br /> yyc License Na. 3 <br /> Contractor's Name,,. Lr <br /> �► N <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT, TRUCTIO ❑LLk <br /> III��� OTHER U <br /> PUMP 1N51AATION ❑ SYSTEM REPAIR FLD.➢15P05AL SEWER LINES PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK 'i— J— OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED OSE TYPE OF WELL PROBLEM AREA Dia. of Well Excavation f <br /> ❑ industrial ❑Open Bottom []Manteca <br /> Trac Dia. of Well Casing <br /> mestic/Private ❑Gravel Pack ❑ Y <br /> ❑ Public ❑ Other ❑Delta Type of Casing <br /> rigation Approx. ❑Eastern specifications - <br /> Depth Depth of Grout Seal C34 <br /> ❑Cathodic Protection , - <br /> ❑Geophysical Type of Grout <br /> ❑other Surface seal Installed by {rj <br /> h H.P. state Work Done <br />` Repair Work Done ❑' Type of Pump Lr <br />` Sealing Material (tap 50') <br /> well Destruction ❑ Well Diameter <br />` Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El <br /> ❑ (No septic tank or seepage pi available withinu200rmitd if cis <br /> feet.) <br /> Installation will serve: Residence _ Commercial i 0th rr° <br /> Number of bedrooms Lot size <br /> Number of living units: Water table depth <br /> Character of soil to a depth of 3 feet: Capacity _ � No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal <br /> pKG. TREATMENT PLT. ❑ Type/Mfg Foundation Property Line <br /> SEWAGE SYSTEM ❑ Distance to nearest: Well <br /> DESTRUCTION Total length/size <br /> LEACHING LINE ❑J No. a length of lines property tine <br /> { FILTER BED <br /> ❑ Distance to nearest: Well Foundation <br /> SEEPAGE PITS ❑ Depths <br /> Size .Number <br /> Foundation _,_� Property Line <br /> j SUMPS ❑i Distance.to,nearest: Well Y <br /> fi o15POSAL PONDS ❑ I ------------- <br /> T� <br /> 1 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 son Joaquin Local Health District. <br /> Home owner or licensed agent's signature ctifies thesucfolloernas to hecomeysuhjectthat nto wothe rkman compensathonwlawsfof California." <br /> permit is issued, 1 shall not employ any person <br /> Contractor's hiring Iubhalltemct <br /> plongps,sona nsurubject�toeworkma s the elloompensationrlaws ofaCaliforniathe erformance of the work for whit <br /> this permitissued, <br /> The applic t ust call or all �e it ins p ctions. Complet ra ng on reverse side. Date. <br /> ! Signed X - �i Title: <br /> 49 i lF`FOR DEP ENT USE ONLY �1 �4Pt f� S 466-6781 <br /> `/f Area OF- <br /> Application Accepted by' . - Lodi 369-3621 <br /> ' Additional Comments: ( = �� 3� IIf r ❑ <br /> Date Manteca 823-7104 <br /> I Pit or Grout Inspection b Date C1 Tracy 835-6385 <br /> 201 <br /> Final Inspection by <br /> � Applicant -'Return all copie o: Enviro mental Health PermitlServices 1601 Haz lton Ave., P.O. Box 2D09, St k., CA 95 <br /> FEE BASE AMOUNT- DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO �?" �7T <br /> 10/82 500 <br /> 'I <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />