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APPLICATION FOR .PERMIT a <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.g- <br /> Telephone (209) 466=6781 DATE ISSUED Z <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ! (Complete in Triplicate) <br /> n is hereby,made to the san-Joaquin Local Health District for a permit to construct and/or install ithe work herein <br /> Applicatioimade is made; in compliance with San .}oaquin County Ordinance No. 549 for sewage or No.- 1862 for well/pump <br /> described. This app <br /> and the Rules and,Regulations of th,'e,san Joaquin Local Health-District. <br /> Job Addressvision Name <br /> Address !n- , Phone <br /> Owner's Name L License No, Phone to <br /> Z 2. � <br /> Contractor's Name F��Ya E wQp� <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> P (� SYSTEM REPAiR OTHER <br /> UMP INSTALLATION <br /> NES DISPOSAL FLD. PROP. LINE <br /> AN <br /> DISTCE TO NEAREST:kSEWER LI <br /> SEPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ; <br /> ❑ Industrial U Open Bottom ]Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Trac <br /> U Domestic/Private Gravel Pack [� y <br /> Public Other El Delta Type of.Casing <br /> V Irrigation Approx. Eastern Specifications <br /> Depth Depth of Grout Seal <br /> Cathodic Protection W <br /> Geophysical Type of Grout -0 <br /> Other Surface Seal Installed by O <br /> Repair Work Done ❑ Type of Pump <br /> H.P. State Work Done 1 <br /> SFiller <br /> Sealing Materf'al (top 50') <br /> ItWell Destruction F-1 Well Diameter' FillMateriat"I Below 50') <br /> Depth _ �. sewer <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ZJ (No septic tank or seepage piavailableewithinu200cfeet- is <br /> _ _ - <br /> Insfallation'will'serve:' Residence--v—Commerci-al,+. -Other w '�- per*°" +- 4. \ <br /> 44 Number of bedrooms �F Lot'si°re,1!1 <br /> Number of living units: �� ; <br /> + , Water #ableRdepth <br /> - <br /> Character of soil to a depth of`3 feet: C .,� - N1 <br /> Capacity No. Compartments <br /> SEPTIC TANK- Typp 6fg '"` Method of Disposal <br /> PKG! TREATMENT PLT. �S�pe/Mf9 T5 Capacity �� , <br /> - S Foundation , Propey Line <br /> SEWAGE SYSTEM �j - Distance to nearest: Well 1 , <br /> iDESTRUCTION 11�� III, I <br /> 11 <br /> Total length/size <br /> LEACHING LINE o. & 'Length of lines 1 l <br /> FILKER BED Dista_ni{e to nearest: Well <br /> Foundation �_ Property Line4. <br /> f N / # �M• <br /> SEEPAGE PITS Depths_ Size _ �8 _ Number s <br /> ' Distance to nearest: Weli Foundation S Property Line j <br /> SUMPS L�I <br /> DISPOSAL PONDS �I r <br /> I hereby certify that I anderulesared regula5 of application andanhJoaquinwLocaI Heaork lthdDistrictone in ccordancewith San Joaquin county + <br /> k ordinances, that <br /> E or which this <br /> Home owner or lj,censed agent's signature certifies suchc, the �mannernas to becvmeysubject ntohworkm�n§ compensation ormance of "the wlaws ork fof.'California." <br /> permit is issued, I.shall.Iiot employ's y.rP <br /> Contra toi'sihiissued, Iu5ha11temp1oy9Qersonsusubject`to workmanpslcompen'satioe�nnllaws ofaCaliforn at°formante of th`e work for which <br /> this p x �'" t.—'P2— <br /> he <br /> + <br /> t- . rt: - . i <br /> ! The applicant must call for al required pections. Com pletedrawing reverse side. Date. 7.� P L <br /> Signed X Title: <br /> . PA MLNT ONL1 3 i �tk- 466-6781 <br /> Application Accepted h ! M Area / <br /> Lodi 369-3621 f <br /> Additional Comments: i Manteca 823-7104 <br /> Date ��� <br /> Pit or Grout Inspectio4: by Tracy 835-6385 <br /> 3 Date <br /> „y,,,,„Final.Inspectionby_ w <br /> Applicant - Return all coQi o: . Environmental Health Per <br /> ces`1601'E7 Hazelton A e.; P.O. 'Box 2009, St k., CA 95201 <br /> AMOUNT DUE AMOUNT REMITTED .._ RECEIVED BY <br /> DATE PERMIT NO. <br /> FEF BASE <br /> INFO g 3 <br /> 10/82 500 <br /> EH 13-24 REV. 10182 - <br /> 14-26 <br />