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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL. HFA.LTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. $3^3 �— <br /> Telephone (209) 466-6781 <br /> GATE ISSUED 4*-1 X3.3 <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 04 <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 Joaquin Local Health District. I <br /> Jab Address 949- Al Subdivision Name <br /> Owner's Name Address J J9 Phone oa <br /> Contractor's Name License No. �S"'1i/— Phone <br /> TYPE OF WELL/PUMP WORK: NEL I!:WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ OpenlBottom ❑ Manteca Dia, of Well Excavation <br /> ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Public Other Delta <br /> ❑ CJ ❑ <br /> Type of Casing <br /> E <br /> LjIrrigation Approx. ❑ Eastern <br /> Depth Specifications <br /> ❑Cathodic Protection Depth of Grout Seal <br /> s ❑Geophysical <br /> Type of Grout �} <br /> �f Other <br /> Surface Seal Installed by (� <br /> Repair Work Done ❑ Type of Pump H.P. State Work Dore J <br /> Well Destruction ❑ Well DiameterIF Sealing Material (top 50') _ 0 <br /> Depth 1 Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is 1 <br /> I v available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other \j <br /> Number of living units: pumber of bedrooms 3_ Lot size *3 g!qe t_ dJ1 <br /> Character of soil to a depth of,i 3 feet: Water table depth /00 <br /> SEPTIC TANK FN Type/Mfg; ��r1 S.� Capacity �6Da No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well �D Foundation _�� Property Line �` <br /> DESTRUCTION ❑ 11 <br /> i <br /> LEACHING LINE No. & L'ength of lines Total length/size 4V X 7— <br /> FILTER <br /> FILTER BED ❑ Distance to nearest: Well Ago Foundation r Property Line �q <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS Distance to nearest: Well /7 <br /> Foundation Property Line <br /> � <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1-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 become subject to workman compensation laws of California <br /> -" <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant must call for all required inspections. Complete drawing on <br /> reverse Jide. <br /> Signed X ` # Title: � c~7"'//!> Date: f8 <br /> I R DEPARTMENT USE ONLY <br /> Application Accepted by l�I • •4�LL11b�-.� Area 0X &-Stk 466-6781 <br /> Additional Comments: i � "f ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by �} <br /> Dat - �-3 ❑ Manteca 823-7104 <br /> Final Inspection by Date ► �'� ❑ Tracy 835-6385 <br /> Applicant - Return all copies to:� E ronm tal Health Permit/Services 1601 E. Hazelton Ave., P.0- Box 2009, St k., CA 95201 <br /> [FEE BASE AMOUNT D AMOUNTREMITTED RECEIVED BY DATEPERMIT N0. <br /> I 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> i 14-26 . M 2 <br />