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JL <br /> APPLICATION FOR PERMIT y <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE„ STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> P W-3 <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 work.herein y <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 Addres Subdivision Name <br /> k Owner's Name Address 3 Q Phone C� <br /> Contractor's <br /> Ki � P „[A6w.K Co License No. vaa Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION [_J 4! <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE-70—N EAREST: SEPT TC TANK DISPOSAL' FL J PROP. LINE! <br /> I FOUNDATION AGRICULTURE Vj �,- PITS/SUMPS <br /> _INTENDED USE —......TYPE OF WELL PROBLEM_AREA„_, _CONSTRUCTiON.SREGIF,ICAT4ON5.El <br /> •-- <br /> Industrial ❑ Open Bottom Manteca Dia. of Well Excavation i <br /> ❑ Domestic/Private ❑Gravel PackTrac <br /> ❑ Y Dia, of Well Casing <br /> ❑ Public ❑Other +. f ❑ Delta <br /> ❑ Irrigation t Type of Casing 'f <br /> Apprgx. ❑ Eastern <br /> E ❑ Cathodic Protection Depth% Specifications ' <br /> ❑ Geophysical t 1 Depth of Grout Seal i <br /> ❑[Other i ” Type of Grout <br /> t Surface Seal Installed bye <br /> Repair Work Done Type of Pump. H.P. State Work Dane = <br /> f Well Destruction Well Diameter ^" r <br /> ❑ Sealing Material (top 50') <br /> Depth Filler Material (Below 501) I ' ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION'' REPAI ADDITION <br /> LI (No eptic tank or. seepage-pit­perrh"itted if public sewer is <br /> Installation will serve: Residence Commercial 6@Otheravailable within 200 feet.) <br /> X11,!12-�G` r-'• <br /> Number of living units: Number of bp4rooms Lot siiery_d, � <br /> Character of soil to a depth of3 feet: ', Ir Water table depth _T� <br /> SEPTIC TANK Type/Mfg <br /> -- ft_ No. Compartments " <br /> PKG. TREATMENT PLT. ❑ Type/Mfg % �. Capacity� Method of Disposal <br /> Distance to nearest:­WelI' undations Property Line <br /> LEACHING LINE Li< No. & Length of lines t[3' Total length/size (� X;Z <br /> FILTER BED ❑ Distance to nearest: Well•" Foundat <br /> _ � ion �� _ Property Line <br /> SEEPAGE PITS [� Depth _Size 3 o ff` Plumber,_ f <br /> SUMPS Distance to nearest; Well undation l DProperty Line <br /> DISPOSAL PONDS <br /> f ! <br /> I,hereby certify that I have prepared this application�an(i� 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,, he.following: "I certify that in the performance of the work for which'this <br /> permit is issued, I shall not employ any personinsuch manner as to become subject to workmant 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." 4 <br /> The applicant st call fo all required inspections. Complete drawing on verse side. i <br /> Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Applica on Accepted by <br /> Area 5tk 466-6781 <br /> Additional Comments: � � Lodi 369-362.1 <br /> Pit or Grout InspectAto <br /> _ Date `Manteca 823-7104' <br /> Final inspection by Date �EHaze <br /> Tracy 835-6385 <br /> Applicant - Return all copinviron ental Health Permit/Services 1 � n Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED REPERMIT NO. <br /> INFO RECEIVED BY DATE <br /> EH 13-24 . REV. 10/82 <br /> 14-26 10/82 500 <br />