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APPLICATION FOR PERMiT <br /> SAN J0AQ1j!N LOCAL HEALTH, DISTRICT PERMIT N0. JF3 _ i 103 <br /> t 1601 E. HAZELTON AVE., STOCKTON, CA !!11 (1� qJ <br /> Telephone (209) 465-6781. DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Health District for a permit to construct and/or install the work herein <br /> Application is hereby made to the`San Joaquin Localuin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> described. This application is made in compliance with San Joaquin <br /> and the Rules and Regulations of the ;San )ooaquin Local Health District. <br /> Job Address S �Jd� AI/ �J Subdivision Name <br /> Address _ <br /> // o�[,- 11' ��C1LG' _LC- Phone%% <br /> Owner's Name � G�, ' G�-�U�/!� <br /> Contractor's Name J J <br /> ' License No. a�t Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT F­i DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER Lj ] <br /> DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OTHER WELL <br /> PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL 0 <br /> INTENDED USE TYPE OFaWELL PR03LEM AREA CONSTRUCTION SPECIFICATIONS ( 1 <br /> IJ Industrial U Open ,Bottom � Manteca Dia, of Wel} Excavation V" <br /> U Domestic/Private F-1 Graver Pack [ Dia. of Well CasingTracy r <br /> Public Other] ❑ Delta Type of Casing <br /> V Irrigation Approx. EJ Eastern Specifications <br /> Cathodic Protection Depth —Depth_of_Grout-Seal.^� <br /> Geophysical Type of Grout <br /> U Other Surface Seal Installed by <br /> Repair Work Done [I Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top.-50'.)� ----- <br /> Depth Filler Material (Below 50') [� <br /> sewer <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage Piavailableewittiinu200cfeet.) is <br /> installation will serve: Residence _ Commercial _ Other <br /> Number of living units: •Number of bedrooms _1:1? Lot-size <br /> ». Water table depth,, ! <br /> Character of soil to a depth of, feet: ? <br /> l�f^/ t Capacity „' No. Compartments �19 �_ <br /> SEPTIC TANK [► Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. Type/Mfg 'Capacity <br /> Foundation Property Line r,- <br /> SEWAGE SYSTEM Distance to nearest: Well _A k <br /> DESTRUCTION —T� <br /> LEACHING LINE ILK No. & Length of lines Total length/size <br /> FILTER-BED Distance;to nearest: Wel} Foundation Pr <br /> operty Line R �� <br /> SEEPAW PITS Depth i Size <br /> �� Number <br /> SUMPS LI Distance to nearest: Well �C f Foundation 1 .•Property Line <br /> DISPOSAL PONDS L7 <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: to"I certify that in the performance of the work for which this <br /> permit is issued, I shallnot <br /> employ <br /> an person i such mannertifies the following6meIscertifyubject tthatrinathecperrformance ofompensation wthe fwork lfor nwhich <br /> or sub-contracting 9 f California.” <br /> Contractor's s hiring ensation laws o <br /> compensation this permit is issued, I shall employ persons subject to workman's p <br /> The applican ust call for 11 required inspections. Complete drawing on reverse side. Date:00 <br /> Signed X / Title: <br /> FOR DEPARTMENT USE ONLY 5tk 466-6781 <br /> Area �._ <br /> i Application Accepted byLodi 369-3621 <br />� Additional Comments: LJ Manteca 823-7104 <br /> 6���to <br /> te <br /> Pit or Grout Inspection Tracy 835-6385 <br /> Fin'91 T1spection by <br /> Applicant - Return all copies x o`: Envir nmental Health Permit/Services 1601 . H zelton Ave., P.O. Box 2009, St k., CA 9520] <br /> DATE PERMIT NO. <br /> I FEE rBASE AMOUNT : DUE. AMOUNT <br /> REMITTED RECEIVED BY <br /> INFO <br /> 10182 500 <br /> EH 13-24 REV. 10/82 <br /> k 14-26 <br />