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APPLICATION FOR PERMIT <br /> SAN JOAQb!N LOEAL HEALTH DISTRICT 1 <br /> 1601 E. HAZELTON AVE„ STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6731 <br /> DATE ISSUED 1 <br /> PERMIT EXPIRES 1 YEAR FROM QATE 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 III e 1 t' ns of the Sar Joaquin Local Health District. <br /> Job Address Wl Subdivision Name <br /> Owner's Name LUAL`Tef- RNOL <) Address $AMC- Phone $IR 7/or. <br /> Contractor's Name '14 M C Ga dr- License No. $ Phone gs sy J <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 vV <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ti <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V <br /> �❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing i <br /> ❑ Public ❑ Other ❑ Delta Type of Casing <br /> V Irrigation Approx. [] Eastern Specifications <br /> ❑ <br /> Cathodic Protection Depth Depth of Grout Seal <br /> ❑Geophysical Type of Grout <br /> ❑Other Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONAIR/ADDITION No septic tank or seepage it permitted if public sewer is <br /> LI REPU ( p p available withi200 feet.) <br /> Installation will serve: Residence Commercial _ Other d J <br /> Number of living units: r Number of bedrooms 3 Lot size AW e A 4.4PL <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ <br /> E) Ig00i TfbV <br /> LEACHING LINE No. & Length of lines Total length/size <br /> 7 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number I <br /> SUMPS ❑I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 workmans 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 applicaQ.y t call /for arequiinspections. Complete drawing on'reverse side. <br /> Signed X fY I4 Title: Date: <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by Area �� ❑ 5tk 466-6781 <br /> Additional Comments: ip ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date X Manteca 823-7104 <br /> Final Inspection by Datez-.2 � �d C Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2069, Stk., CA 95201 <br /> ------------------------------------------------------ <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PER­ <br /> Eh <br /> MIT N0. <br /> INFO 13-24 REV: 10/82 '` 10/82 500 <br /> 14-26 ` <br />