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APPLICATION FOR PERMIT <br /> SAN JOAQLiN LOCAL HEALTH DISTRICT / <br /> 1601 E, HAZELTON AVE., STOCKTON, CA PERMIT NO. 9-3- Lp Q� <br /> Telephone (209) 466-6781 j J <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM 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 conpliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rul e aTd (2Pations of the San Joaquin Local H lth District. /� <br /> Job Address_os� N R�� (��Gel /�d7 Subdivision Name Arcer 01?f A0 -1;?f <br /> Owner's Name r�� /1!� Address �1 Phone $5 '/ /_ <br /> Contractor's Name f�n/rdtl��.r_[ /� ��� License No. Phone �U <br /> TYPE OF WELL/PUMP WORK: NEW WELL '� WELL REPLACEMENT [] DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR U OTHER U ( 1 <br /> DISTANCE TO NEAREST: SEPTIC TANKS I SEWER LINES DISPOSAL FLD. �(S� PROP. LINE ! <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v D <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca Dia, of Well Excavation <br /> — /-A <br /> Domestic/Private F7 Gravel Pack Tracy Dia. of Well Casing <br /> 0 Public f—fOther Delta Type of Casing p� / <br /> V Irrigation Approx. Eastern �6 <br /> Depth Specifications <br /> Cathodic Protection - i Depth of Grout Seal <br /> Geophysicalr <br /> Type 'of Grout <br /> LJ Other <br /> Surface Seal Installed by <br /> Repair Work Dane ❑ Type of Pump t H.P. State Work Done <br /> Well Destruction LJ Well Oianeter Sealing Material (top 50`) <br /> Depth Filler Material (Below 50') + j' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/,4DDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of%soil to a depth of 3 feet: plater table depth <br /> SEPTIC TANK Cj Type/Mfg ` Capacity No. Compartments <br /> PKG, TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest:; Well Foundation . Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines' Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS L Distance to nearest: Weil 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 it 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 workmar� compensation laws of Californ.ia." 1 <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 applicant m IT r al Muirspections. Complete drawing o reverse side. <br /> Signed X � Title: ,�/ICALn Date: IAL <br /> x7 <br /> ` FO DEPR NT USE ONLY <br /> Applicatio cepted by _/�� Area i Stk 466-6781 <br /> Additional omments: Lodi 369-3621 <br /> Pit or Grout Inspection by - Date Manteca 823-7104 <br /> Final Inspection by Date _KAO__53 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO 8 <br /> EH 13-24 REV. 10/62 3- ` 48 500 <br /> 14-26 <br />