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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application. VV-hereby made to the San Joaquin Local Health District far a permit to construct anG/or install the work herein <br /> described. .:�Thi's application is made in compliance with San ]oaquin County Ordinance No.549 for sewage or�oN��rwell/pump <br /> -and the :Rules and Regulations <br /> t of�the San Joaquin Local health District. /L`? <br /> i Job Address' �s. O W�VV\(k\A Subdivision Name (+� <br /> Owner's Name u, CY1Q�{� Address G 'y <br /> Phone SR <br /> Contractor's Name �" @� <br /> License No. <br /> I& <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR D OTHER4 U <br /> DISTANCE TO NEAREST: SEPTIC TANK ,_ SEWER LINES DISPOSAL LLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [J- Industrial Open Bottom Ll Manteca Pia., of Well Excayatio.n <br /> jJ Domestic/Private ❑ Gravel Pack Tracy pia. of Well Casing <br /> Public 7Other Delta Type of Casing <br /> I LjIrrigation Approx. [] Eastern Specifications <br /> Depth � <br /> Cathodic Protection DepDepth of Grout Seal <br /> 1-1 Geophysical Type of Grout A4 <br /> ED Other Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. <br /> State Work Done <br /> Well Destruction Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: ' NEW INSTALLATION �� REPAIR/ADDITION � (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) 'J <br /> Installation will serve: Residence Commercial Other /J( <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 TANKType/Mfg Capacity No. Compartments <br /> Capacity Method of Disposal <br /> PKG. TREATMENT PLT. Type/Mfg <br /> r� SEWAGE SYSTEM Distance to nearest: Well Foundation Property. Line <br /> k DESTRUCTION <br /> LEACHING LINE U No. Length of lines Total length/size <br /> & <br /> C' <br /> FILTER RED Distance to nearest: Well Foundation Property Line �G <br /> t 1 <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS. Distance to.nearest: .Well Foundation _ Property Line <br /> i <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 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-becomeIscertif ubject tthatrinathecpePforman�e ofn I wthefworkCal�fornwhich <br /> Contractor's hiring or sub-contracting signature certifies the following:,." y <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> - r <br /> The applicant must c for all requi ed inspections. Complete drawing on reverse side. <br /> Signed X <br /> Titl �e- Date: / �2 <br /> D EPARTMENT ��NL 7-S' r / Q Stk 466-6781 <br /> Applicati n Accepted bye rea <br /> Lodi 369-3621 <br /> Additional Comments: i Manteca 823-7104 <br /> Pit or Grout Inspection by Date <br /> Final Inspection by <br /> ,4 , Tracy 835-6385 <br /> S Date <br /> Applicant - Return all Copies to-, Environmental Heal h ermit Services 1601 E. Hazelton Ave., P.D. Box 2009, St k., CA 95201 <br /> FEE BASE AMOUNT DU AMOUNT REMITTED RECEIVED`BY DATE PERMS? N0. <br /> INFO -A , <br /> / a 1 • .� .a <br /> �-fdfz �jee J"t t,1 i�.~�.I(_ In/�2 snn <br /> EH 13-24 REV. 10/62u6�b` v <br /> 14-26 <br /> a� G,her, t Y',[�vYncJ�,-ev�ryfi--'+iij=�,,r� �a v�v;eat'e�Ge►r•ei,.'f` <br />