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►., A , <br /> UPAPL�ICATI04 &(1 }t} �{} Q LOCA_ ,_LTH DISTRICT <br /> 1601 E. HAZELTON AVE. STOCKTON, CA Q <br /> Telephone (209) 466-6781 PERMIT N0. v 7'��Z <br /> SAN JQAQUINN LOG EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> HEALTH DiSTRI (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> permitl the <br /> described. This application is made in compliance with San Joaquin County 0 dinancecNo. 549tfardsewagesorlNo. 1862rforewell/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address SuLd;,,; ;an Name <br /> Owner's Name W//i�g� Ce .F' Address <br /> Contractor's Name Pgp,e1 ,,� �--gA To�/�Tp.-) Phone }fig—V-61k <br /> N_5 License No. SSSi/-T Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL C WELL REPLACEMENT <br /> DESTRUCTION <br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> II <br /> INTENDED USE TYPE OF WELL PROBLEM AREA <br /> CONSTRUCTION SPECIFICATIONS J Industrial C Open Bottom <br /> (J Domestic/Private Bottom [I]Manteca Dia. of Well Excavation <br /> Gravel Pack C Tracy Dia. of Well Casing <br /> C Public C Other ❑ Delta <br /> LjIrrigationType of Casing <br /> Approx. � Eastern <br /> [ Cathodic Protection Depth Specifications <br /> ❑Geophysical Depth of Grout Seal <br /> LJ Other Type of Grout p <br /> Surface Seal Installed by fttN <br /> Repair Work Done C Type of Pump H.P. <br /> State Work Done <br /> Well Destruction C Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C REPAIR/,ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: ResidenceCommercial _ Other available within 200 feet.) Q <br /> Number of living units: _� Number of bedrooms <br /> Lot size <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> C Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. C Type/Mfg \\ <br /> Capacity Method of Disposal <br /> SEWAGE SYSTEM 1�--�l Distance to nearest: Well <br /> DESTRUCTION LI Foundation Property Line <br /> LEACHING LINE C No. & Length of lines <br /> Total length/size <br /> FILTER BED Distance to nearest: Well <br /> Foundation Property Line <br /> SEEPAGE PITS Depth Size ' / <br /> Z Number <br /> SUMPS �� Distance to nearest: Well foundation ' <br /> DISPOSAL PONDS Property Line <br /> C <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 issue I shall not employ any person in such manner as to become subject to workman compensation laws of California." <br /> Contractor's h' ing or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit i ssued, I shall employ p sons subject to workman's compensation laws of California." <br /> The applican call for 11 req" inspe ions. Comple drawin n reverse side. <br /> Signed <br /> Title: Date: tE Z <br /> OR T� <br /> Application Accepted by FDEPARTMENT USE ONLY,n Area C.J � Stk 466-6781 <br /> Additional Comments: <br /> Lodi 369-3621 <br /> Pit or Grout Inspection Date <br /> C Manteca 823-7104 <br /> Final Inspection by Date <br /> 3 /� Tracy 835-6385 <br /> Applicant - Return all copies to: Envir nmenta Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO I <br /> EH 13-24 REV. 10/82 <br /> 14-26 10/82 500 <br />