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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO"QIR � 7aS <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 workherein <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 Loca-1 Health District. <br /> Job Address A 77 3 MA& aSO kGA0 5761KIWSubdivision Name <br /> Owner's Name IJOSKY (-QA JE- r�C Address ol "l3 rKrk*Z o5q <br /> Contractor's Name /Y + � Phone <br /> 5 Arr�F -- License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW 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 d <br /> Industrial ❑Open Bottom Manteca r� <br /> ❑ Dia. of Well Excavation V 1 <br /> ❑ Domestic/Private ❑Gravel PackTrac <br /> Public ❑ Y Dia. of Wel] Casing <br /> 17 [j Other D Delta <br /> LjIrrigation Type of Casing <br /> Approx. � Eastern <br /> Cathodic Protection Depth Specifications ' <br /> ❑Geophysical Depth of Grout Seal <br /> Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.F. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence _ Commercial Other Grl;T,c.e /5./ fsy„A�aiT ble within 200 feet.) w <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: c4ey Water table depth �1 <br /> SEPTIC TANK Fd, Type/Mfg KIIJ r Capacity -_Z­yUo No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> Septic Tank Distance to nearest: Well Foundation G ` Property Line <br /> Destruction 0 _1 P y _f.6`¢ <br /> LEACHING LINE No. & Length of lines r Total length/size ' <br /> FILTER BED [] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size <br /> Size , 3” Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ce"l� <br /> �f� r <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 become subject to workman compensation laws of California." <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 oy persons subject to workman's compensation laws of California." <br /> The applicant must 11 equired inspections. Complete dron revere side. f <br /> Signed X v <br /> x_ Title: �4.� Dater2-3 +Z. <br /> FO$.DI ARTME T_11SE ONLY <br /> Application Accepted by � � Ct, Area !J / <br /> � Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by _l Date Manteca 823-7104 <br /> Final Inspection by Date Tracy 835-638AV)//, <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton AV)//, P.O. Box 2009, Stk., CA 95201 ��rZ <br /> FEESASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFO DATE PERMIT N0. <br /> _7� <br /> EH 13-24 REV. 10/82 <br /> 14-26 " 10/82 500 <br />