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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Z L 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <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 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 /> Job Address LG +_ Ll,'f�� t,i2TD{" Subdivision Name <br /> Owner's Name �.'S �yU`�1;�}�`f Address C 9.1Frl Phone J '" <br /> Contractor's Name L' _i��LL e—mss IA License No. _ � y° Phone A, <br /> r <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 l <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS W <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O 1 <br /> 17 Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation <br /> i <br /> Domestic/Private �Gravel Pack � Tracy Dia. of Well Casing <br /> Public , Other EiDelta <br /> irrigation Type of Casing <br /> V g Approx. Eastern <br /> Depth Specifications <br /> E)Cathodic Protection p Depth of Grout Seal <br /> Geophysical Type of Grout <br /> other Surface Seal Installed by t, 1.Q> LL <br /> i <br /> Repair Work Done 0 Type of Pump 3 H.P. i.LR State Work Done 1-PJSTA LL, <br /> —Well-Destruction U--Wel-1,Diameter" -"' 'Sealing Material (top 50') Q <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IJ REPAIR/ADDITION [J_ (No septic tank or seepage pit permitted if public sewer is <br /> N available within 200 feet.) <br /> Installation will serve: Residence _ Commercial Other <br /> Number of living units: Number of bedrooms Lot size f <br /> Character of soil to a depth of 3 feet: Water table depth t <br /> SEPTIC TANK EI Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. '] Type/Mfg Capacity Method of Disposal <br /> T Distance to nearest: Well Foundation Property Line <br /> LEACHING•LINE L 1 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 ❑ 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 i ued, I shall not employ any person in such manner as to become subject to workman s compensation laws of California." it <br /> Contractor' hiring or sub-contracting signature certifies the following: "I certify that in the performance of the_work for which 4 <br /> this permi"issued ll ploy arsons subject to workman's compensation laws of California." <br /> The applic r uir inspections. Complete drawing on reverse side. <br /> Signed X Title: S�et-J_,cs Date: rJ fr3 <br /> /v F DEPA <br /> Application Accepted by ENT USE ONLY_ �,C �Area ®7-- 1Z Stk 466-678 <br /> Additional Comments: E] Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104- <br /> Final <br /> 23-7104Final Inspection by Date � E] 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 /> 1 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />