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` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HE4LTH JiSTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. � 7 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 /> and the Rules and Regulations of the San.Joaouin Local Health District. <br /> Job Address Z L . HAQ4 L Subdivision Name <br /> Owner's Name if Address Z 1%.> u) - Phone i� Q <br /> Contractor's Name ( G 1,J+ELL G E P License No. 60 Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION NZ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U O� <br /> DISTANCE TO NEAREST: SEPTIC. TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> " . FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS <br /> INTENDED .USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^t1 <br /> II J Industrial ' sv U Open Bottom Manteca Dia. of Well Excavation <br /> Domestic/Private �1 <br /> U � Gravel Pack � Tracy ,Dia. of. Well Casing <br /> Public r7i Other E] Delta <br /> Lj Irrigation Approx. Eastern Type of Casing <br /> Specifications <br /> [Cathodic Protection Depth + Depth of Grout Seal <br /> Geophysical f <br /> 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) F- _ <br /> Depth N Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONfL_I REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence x Commercial _ Other <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 F-1 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> r <br /> LEACHING LINE {J No. & Length of lines ` Total length/size" ) + <br /> { <br /> FILTER BED Distance to nearest: Well Foundation Property-;Line <br /> SEEPAGE PITS rl Depth Size Number ` <br /> SUMPS L Distance to nearest: Well Foundation Property Line <br /> 4 <br /> DISPOSAL PONDS } <br /> U1�14• i l l i•11�� iii y 1 <br /> I hereby certify that 1 have prepared ,this application and that theswork 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 o licensed agent's signature certifies the following:; "I_certify`that .in the performance of the work for which this <br /> permit is i su d, I shall not employ any person io,.such manner as-to become subject to workmans compensation laws of Califormia." <br /> Contractor' ' ring or sub-contracting signature cer.tifies the following:' ;'I certify that in the performance of the work for which' <br /> this permit i issued shall empLied <br /> o s subject".to workman's compensation laws oil California." <br /> Thea lic ust ca 1 r all en 4pppec tions. .Complete awing an reve se side. P <br /> Signed X /Title: c���� Date: 1 <br /> 1{ h7 <br /> . <br /> FO ARTMENT.USE ONLY' <br /> " Appl icatf on A ted by - � �� --- Area l- - Stk-•••----466-6781 ,-.-_r._ _. <br /> Additional Comments: _ww F-] Lodi 369-3521 <br /> Pit or Grout Inspection by a Date: s L�'_ Manteca 823-7104 <br /> � Final Inspection by �,7D�to a ``"� Tracy 835-6385 <br /> Applicant - Return .all copies.to: . Environmental Heat P rmit/Services 1 01 Haze on Ay�� P.O. Bax 2009, Stk., CA 95201 { <br /> FEE BASE AMOUNT DUE = AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 10/82 500 <br /> EH 13-24 REV. .10/82 <br /> 14-26 <br /> y � 1 <br /> 1 <br />