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�'"-<i <br />ft <br />APPLICATION FOR PERK T <br />SAN JOA(W) LOCAL HEALTii 01STPICT ' <br />,SDI E. HAZELTON AVE,. STOCKTON, CA PERMIT NO. *� i�'�� �. <br />Telephone (209) 466-5781 <br />DATE ISSUED <br />PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Complete Wl`riolicatt) 1. <br />Application is hereby made to the Sara Joaquin Local Health District for a permit to construct anb/or'insta'l. the work herein <br />described. This application is sarde'in compliance with San Joaquin County Ordinance No. 599 for sewage or No. 1862 for well/pu <br />and the Rules R gulations of thelSan Joacuin Local health District. <br />Job Address � ow Subdivision Name <br />Owner's Name_ Address one <br />Contractor's Name # License No, Phone <br />TYPE OF +TELL/PUMP WORK: NEW Ilht. [] WELL REPLACEMENT [i DESTRUCTION F <br />PMP INSTALLATION {❑ SYSTEM REPAIR OTHER U <br />DISTANCE TO NEAREST: SEPTIC TANK SERER LIKES DISPOSAL FLO, ill'. LINE <br />FOUNDATION ,____ AGRICULTURE WELL OTHER WELL PITS/WS <br />INTENDED USE TYPE OF,WELL PROBLEM AREA C0#STRUCTION SPECIFICATIONS <br />Industrial 0 Open Bottom ;Man teca Dia, of Well Excavation <br />Jomeltic/private M Gravel' Pat k Tracy Dia. of Well Casing <br />Public <br />Irrigation �J Other � � Delta Type of Casing <br />Approx. Eastern specifications <br />Cathodic protection Depth <br />Geophysical Depth of Grout -Seal <br />i_i Other Type of Grout <br />Surface Seal installed by <br />Repair Work Done Type of Pump H. P. State Work Done <br />Well Destruction well Diameter ' Sealing Material (top 501) <br />Depth Filler Material (Below 5D') _ <br />, <br />TYPE Of SEPTIC WORK: NEW INSTALLATION r-1 REPAIR/ADDITION C] (No septic tank or seepage pit permitted if Poulin steer is <br />1 <br />available within $00 feet.) <br />Installation will serve: Residence. Commercial _ _ Othe+- <br />Number of living units: Number of bedrooms Lot size <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br />PKG. TREATYXXT PLT. n Type/Mfg a Capacity Method of Disgesal <br />SEWAGE SYSTEMDistance tz nearest: iii _ Foundation Property Line <br />_ DESTR'UCTION Q I _ <br />LEACHING LINE r—! No. Z Length of lines � Total legth/size <br />FILTER RED E] Distance to nearest: Well foundation Property Line <br />SELPAGE PITS n Depth _ ? Size Number <br />SUMPS L' Distance to nearest: Well Foundation _ _ Property Line . <br />DISPOSAL PONOS L <br />hereby certify that I have preparZd this application and that the work will 'be done in accordance with San Joaquin county <br />ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, <br />Hose owner or licensed agent's signature certifies the following: "I certify that it the performance of the work for t %fi this <br />permit is issue. I shall not er.pigy any person In such wanner as to become subject to workmen+ compensat'10" laws of telif*rnia." <br />Contractor's hiring or sub -contracting signature certifies the following: "I certify that in the perfQroiwce of the work for which <br />this permit is is$ ed, I shall ploy persons Subject to wprkman`s caIpeisation lams of California." <br />The Appl c 8t tall or i reg4lred inspections. Complete d reverse side. <br />Signed X Title: Date: <br />Application Accepted by # ART!+ENT S€ ONLY Area <br />Jtk <br />Additional Comments- fgLod1 -362: <br />Pit or Grout Inspection by. _ Date Lj Manteca 823-7104 <br />Finai Inspection by - Date` W j Tracy 836,4385. <br />Applicant _ Return all copies to: Err i� � ntal Health Pen t/Services 1601 E. Hazelton AX., P.D. Box 20,,Stk., CA 95201 <br />FEE 3 BASE �~~�AMCUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE T PERMIT N0. <br />INFO--�` —" <br />EH 13-24 REV. 10/82 � �� C�..,.r� 10/82 Sao <br />14-25 <br />