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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781, DATE ISSUED3 rl <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ' 4 <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 /> Jab Address 3 a,5-60 P Subdivision- Name <br /> Owner's Name s � Q Address Phone <br /> Contractor's Name, L.E E )�h, ALIALt License No. Phone <br /> Cl, � <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -.DISP.OSAL PLO. ✓ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ir1 Industrial U Open Bottom [] Manteca Dia. of Well Excavation <br /> Lf Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing <br /> Public F-1 Other [Delta Type of Casing <br /> ..k••�.,,.� ---- ,,�.,� --,-. t <br /> Lj' g Appro'x' [� Easterner~^ -IT-Specifications <br /> Cathodic`Protection Depth <br /> Depth of Grout Seal <br /> 1-1 Geophysical 1 <br /> Type of Grout <br /> U Other r ww Surface Seal Installed by U"- <br /> Repair Work Done ❑ Type of Pump H•P, State Work Done (yam] <br /> Well Destruction U Well Diameter 4. i Sealing'Material((top 50') <br /> Depth € Filler Material (Below 50'), <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/flODITION �t�(No <br /> septic tank or seepage pit permitted if public sewer isavailable within 200 feet.) <br /> Installation will serve: Residence Commercial her t <br /> Number of living units.: °'�"�`° Number of bedrooms Lot size 1 <br /> f <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. Type/Mfg Capacity Method of Disposal <br /> SEWAGE STEM Aj.s•tance to nearest: Well Foundation :Property Line <br /> DESTRUCTION-. Q <br /> LEACHING LINE"-'"-D ` No. :& Length of lines Total length/size' <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS < g Depth _ Size Number <br /> SUMPS Distance to nearest: Well Foundation - Property Line <br /> DISPOSAL PONDS d <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,li.censed 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 workman compensation laws of California." <br /> Contractor'.s'hYT1li`g`of sub:cont-racftinC"Si'gn-Stur`e'certi'fie-s�-the-"fol'l-owirig,:-`I`cert'iffy-that-in-the performance of the work-for-which__ <br /> emit is issued, I shall employ persons subject to workman's compensation laws of. California." <br /> T appl t mus cal for 11 equi ed'inspections. Complete drF* g.on.re erse sid <br /> Sign Title:..` Date: <br /> t OR PARTMENT USE ONL <br /> Application Accepted by F Area y Stk 466-6781 <br /> Additional Comments: I ,�I Lodi 369-3621 <br /> • Pit °or Grout Inspection by Date Manteca 823-7104 <br /> � <br /> Final Inspection by Date L Tracy 835-6385 E <br /> Applicant Return all copies to: . Environmental Health Permit/Services 1601 E. Hazelton`Ave., P.0- Box 2009, Stk., CA 45201 <br /> t rINFO <br /> BASE AMOUNT DUE AMOUNT.REMITTED RECEIVED BY F DATE PERMIT NO. <br /> ' <br /> 5,u S o a 3/a►/S3 �3-t39 <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />