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a <br /> APPLICATION FOR PERM 7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. -17 <br /> Telephone (209) 466-6781tt ,, <br /> DATE ISSUED <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 <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 / A/ Subdivision Name <br /> Owner's Name Address p ,Q Phone 94$-4�cl(L �l y <br /> Contractor's Name _ F"yZ> ,#G, yq/0p j License No, 42--l-a2k Phone 1 <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 ti- OTHER AELL PITS/SUMPS <br /> INTENDED USE TYPE DF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom ,_F-1 Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack ❑Tracy Dia. of Well Casing <br /> 17 Public Other El Delta Type of Casing <br /> F71Irrigations- Approx!­F ❑ Eastern <br /> Depth Specifications <br /> Cathodic Protection <br /> Depth of Grout Seal _ <br /> Geophysical \ <br /> Type of Grout Ln <br /> U Other 0 <br /> Surface Seal Installed by � <br /> e <br /> Repair Work Done ❑ Type of Pump H.P. State Work-Done - <br /> Well Destruction U Well Diameter "�� Sealing•Material (top 50') <br /> Depth Filler Material (Below 501) _ O <br /> r � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J/ (No septic,tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: A Y __ Water table depth <br /> SEPTIC TANK [k" Type/Mfg L Capacity 1-2-!!A No. Compartments �. <br /> PKG. TREATMENT PLT. E]—Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation le Property Line <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines / -- f Total length/size <br /> FILTER BED Distance to nearest; Well AJ 1A� Foundation 149 Property Line_ <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation 10 f Property Line (Q f <br /> DISPOSAL PONDS �I <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 applicant must call for 11 r uired inspec 'ons. Complete dra 'ng on reverse side, <br /> Signed X Title: Date: <br /> 0USE ONLY <br /> ARTMENT <br /> Application Accepted by Area 7 Stk 466-6781 <br /> Additional Comments: k,71Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-1104 <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE OUNT DUE AMOUNT REMITTED.. . RECEIVED BY DATE PERMIT NO. <br /> INFO A <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />