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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON. CA PERMIT N0. 7 <br /> Telephone (209) 466-6781 '" <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED AVL3 <br /> 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 <br /> Subdivision Name <br /> Owner's Name Address e W �h?e <br /> Contractor's Nam lt+L�++EPhone <br /> e3 License No. Z Z{4 <br /> Phone /Q <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION EJ SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES DISPOSAL Fpu ' <br /> LD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION .SPECIFICATIONSW~ r <br /> Industrial U Open BottomManteca .-Q <br /> Domestic/Private � Dia. of Well Excavation <br /> Gravel Pack ❑ Tracy Dia. of Well Casing <br /> 17 Public Other <br /> �J 0 Delta <br /> U Irrigation Approx. ❑ Eastern Type of Casing <br /> Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> CJ_ Other --Type of Grout <br /> Repair Work DoneT e of Pum Surface Seal Installed by <br /> �-� yP p ..� H.P. State Work Done <br /> Well Destruction (J Well Diameter Sealing Material (top 50') <br /> Depth <br /> Filler Material (Below 501) <br /> vTYPE-OF 7SEPTIC WORK: NEW INSTALLATION`U---REPAIR%ADDITI(jN _ <br /> (No septic-tanR'or seepage pi�permitied if public-se <br /> we <br /> Installation will serve: Residence *_11 Commercial _.,Other available within 200 feet.) <br /> Number of livingunits / <br /> : r Number of drooms Lot size <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKLLT1/ Water table depth _ -70 <br /> Type/Mfg Capacity No.-Compartments <br /> PKG. TREATMENT PLT. Type/Mfg <br /> Capacity ^��� Method of Dispose] <br /> Distance to nearest: Well "f Foundatio4 <br /> '!1" Property Line <br /> LEACHING LINE N <br /> No. & Length of lines ^^ �To'tgth/size�40 <br /> FILTER BED Distance to nearest: Well <br /> �_ Foundation - Z 0 f Property Line <br /> SEEPAGE PITS Depth - T Size 1 <br /> Numberi <br /> SUMPS U Distance to nearest: Well r�^ Foundation <br /> DISPOSAL PONDS Property Line - -S <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 cerfify 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 wo.rkman's compensation laws of California.,, <br /> The applican ust call al required inspections. Complete-drawing o verse side. <br /> Signed X <br /> Title: . Date: <br /> Applica Ian Accepted by OR DEPARTMENT USE ONLY <br /> Area Stk 466-6781 <br /> Additional Comments: A d, <br /> Pit or Grout Inspectio �Lodi 369-3621 <br /> Date <br /> Final Inspection by Q Manteca 823-7104 <br /> "� <br /> h Date O Tracy 835-6385 <br /> Applicant - Return all copies to: Envir nmental Health Permit/Services �1601 E. H el tan Ave., P.O. Box 2009, Stk., CA 95201 <br /> FIE0 BASE AMOUNT DUE AMOUNT REMITTED ' — RECEIVED-BY DATE PERMIT NO. <br /> a �3 f3- �7 <br /> EH 13-24 REV. 10/82 <br /> 14-26 10/82 500 <br />