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<br /> APPLICATION FOR PERMIT - ~
<br /> l
<br /> SAN JOAQUiN LOCAL HEALTH -DISTRICT
<br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.
<br /> ' Telephone (209) 466-6781
<br /> I PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED
<br /> (Complete in Triplicate) `4
<br /> Applicatibn 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. 1662 for well/pump
<br /> and the Rules -and-•Regulations of the,San-Joaquin Local Health District.
<br /> Job Address Q 3 Subdivision Name
<br /> -
<br /> Owner's NameFla LA A Vim.VHF Add �� s(���
<br /> --__. . .:. Phone
<br /> Contractor's Name �, ress iIVAG.r�_5��
<br /> ra License No. .. Phone
<br /> —
<br /> TYPE OF WELL/PUMP WORK:- NEW WELL
<br /> ❑ -WELL REPLACEMENT ❑ DESTRUCTION ❑
<br /> } PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES
<br /> I. DISPOSAL FLD, PROP. LINE
<br /> FOl1NDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS
<br /> INTENDED USE TYPE OF WELL PROBLEM AREA01
<br /> CONSTRUCTION SPECIFICATIONS
<br /> Industrial - -.. _.-,.__ _ b❑ Open Bottom ❑ Manteca�� Dia, of 4lel l Excavation x " :''1
<br /> ❑ Domestic/Private Gravel Pack Trac ?
<br /> f ❑ Y Oia. of Well Casing {}�
<br /> ;❑ Public Other ,
<br /> ❑ ❑ Delta _
<br /> Irrigation Approx. Eastern
<br /> T9 <:pe .of Casi:n9<
<br /> —.,De tb,_ Specifications
<br /> :❑Cathodic
<br /> t❑Geophysical Depth of Grout Seal
<br /> U Other } r,5,, :' ) Type of Grout
<br /> :i Surface Seal Installed by
<br /> Repair Work Oone Type of�Puinp H.P. '� -.`_,
<br /> a ❑ State Work Done
<br /> Well Des truction, .•- We17 Diameter__. Sealing Mat1
<br /> eria. •(top 50') ,
<br /> lJ __.. _...._
<br /> Depth :r Filler Materia (Below 50')
<br /> ,TYPE OF,SEPTIC WORK:, NEW INSTALLATION REPAIR/ADDIT'ION J❑ -,,(No septiC:�.tank or seepage pit permitted if public sewer is
<br /> } to available within �0_,feet,,,)
<br /> t Installation will serve:^-Residence~�.Commer,Ci4a9' ; Other_.: - '-
<br /> Number of living units: } Number of bedroam5 M1 Lot 'd e
<br /> Character of soil to a dptfi o 3 feet Water table depth 6�;
<br /> � .- k, -
<br /> SEPTIC TANK 7y �Mfg _ sj �.. _ Capacity 1,;249p No. Compartments __3
<br /> RKG, TREATMENT PLT. 'T ..
<br /> ❑ ypeMfg Capacity Method of Disposal
<br /> SEWAGE SYSTEM. ,��.. Dis�tance,to nea�ds't "'Well Foundation Property Line
<br /> DESTRUCTION ❑ j ` + �. �.j_
<br /> LEACHING LINE'. L' N6." & Length of lines Total length/size; y
<br /> ;FILTER BED 1' ibis„tance to nearest: Well t Foundati,o p y
<br /> S ❑ 1 [T # Pro ert Line `
<br /> iSEEPAGE PITS ❑ Depth 5iieNumber
<br /> ` f ;
<br /> (SUMPS ! Distance tonearest: Well ; Foundat.i.onProperty Line
<br /> EDISPOSAL PONDS ' ❑ :I �..-_� _. _+
<br /> I hereby certify f6f_l`have p epared this application and that the work will be done in accordarl a with'San Joaquin county
<br /> )ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.”
<br /> Home owner or
<br /> _licensed agent"s signature certifies the following: "I certify that in the performhnce of the work for which this #
<br /> (permit is issued, I shall not employ any person in such manner as to become subject to workmant compensation laws of California."
<br /> !6Contractor'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." i =
<br /> e
<br /> The applicant must call or 11 required inspections, Complete drawing on reverse side.
<br /> Signed X aTitle: ./ _ ,'- <� Date: �C?
<br /> ` OR R E T USE ONLY ✓• I
<br /> Application Accepted b i
<br /> Pp P Y Area ❑i Stk 466-6781 f
<br /> Additional Comments: Lodi 369-3621
<br /> Pit or Grout Inspection y Date ❑ Manteca 823-7104 .
<br /> Final Enspectio'niy Date _ � Y E" Tracy ' 835-6385 #
<br /> j
<br /> ,Applicant - Return all copies,lto: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2.009, Stk., CA 95201
<br /> ii
<br /> FEE BASE AMOUNT DUE AMOUNTREMITTED _ RECEIVED BY DATE PERMIT NO. i
<br /> ( INFO
<br /> tA
<br /> . _.. .,.. £H .I3-,24.x.,,REV._10/8.2"K,� ....H a�......� ;._.,_,5. ..� ,- _ - � � �r 10/$2..500.,...�.»--...��.,.-.--•--�.'.,..w;?
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