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' APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />6 <br />PERMIT NO. q Imo/ <br />DATE ISSUED <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 Joaquin Local Health District. <br />Job Address• :;�f / <br />ly <br />nt Subdivision Name D�R <br />Owner's Name — -/I�f j� y}�� Addres Pe. [Ax mx_-1 A4/ 'A V,a % Phone <br />Contractor's Name License No. Phone -St, <br />—,Z -&Y6 <br />TYPE OF WELL/PUMP WORK: NEW WELL [V WELL REPLACEMENT [ DESTRUCTION F-1 <br />PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER <br />DISTANCE TO NEAREST: SEPTIC TANK1 <br />SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL [Q PITS/SUMPS <br />O4 <br />�'1 <br />INTENDED USE <br />TYPE OF WELL <br />PROBLEM AREA <br />CONSTRUCTION SPECIFICATIONS <br />�! <br />Industrial <br />U Open Bottom <br />Manteca <br />Dia, of Well Excavation <br />Final Inspection by <br />Domestic/Private <br />5KGravel Pack <br />Tracy <br />Dia. of Well Casing. N <br />Environmental Health Permit/Services 1601 E. Hazelton <br />Ll Public <br />F-1 0ther <br />Delta <br />T <br />Irrigation <br />Approx. <br />❑ Eastern <br />Type of Casing <br />❑ Cathodic Protection <br />Depth <br />Specifications <br />Geophysical <br />Depth of Grout Seal <br />[J_ Other <br />Type of Grout <br />Surface Seal Installed by <br />Repair Work Done Type <br />of Pump <br />N.P. <br />State Work Done <br />Well Destruction U Well <br />Diameter <br />Sealing Material (top 501) <br />Depth <br />Filler Material (Below 501) <br />TYPE Of SEPTIC WORK: NEW <br />INSTALLATION U <br />REPAIR/ADDITION <br />LI (No septic tank or seepage pit permitted if public sewer is <br />n <br />Installation will serve: <br />Residence _ <br />Commercial <br />Other available within 200 feet.) <br />Number of living units: <br />Number of <br />bedrooms <br />Lot size <br />Character of soil to a depth of 3 feet: <br />Water table depth <br />SEPTIC TANK Cj <br />Type/Mfg <br />Capacity No. Compartments <br />PKG. TREATMENT PLT. <br />Type/Mfg <br />Capacity Method of Disposal <br />Distance to nearest: <br />Well <br />Foundation Property Line <br />LEACHING LINE U <br />No. & Length of lines <br />Total length/size <br />FILTER BED <br />Distance to nearest: <br />Well <br />Foundation Property Line <br />SEEPAGE PITS F_� Depth Size Number <br />SUMPS U Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS4 <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 employ persons subject to workman's compensation laws of California." <br />The applicany must call for aA required inspections. Comple e dwing reverse side. <br />Signed X <br />Title: C <br />E RTMEN USE 0 LY <br />Application Accepted by <br />rea <br />❑ <br />Stk 466-6781 <br />Additional Comments: <br />[] <br />Lodi 369-3621 <br />mit or Grout Inspection by <br />Date <br />Manteca 823-7104 <br />Final Inspection by <br />Date <br />Tracy 835-6385 <br />icant - Return all copies to: <br />Environmental Health Permit/Services 1601 E. Hazelton <br />Ave., P.O. <br />Box 2009, Stk., CA 95201 <br />FEE <br />BASEAMOUNT <br />DUE AMOUNT REMITTED RECEIVED BY <br />DATE <br />PERMIT NO. <br />INFO <br />EH 13-24 'REV. 10/82""�r 7 �/ f �� <br />14-26 ! Ue <br />(/L IO/82 500 <br />