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I <br /> I. APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON,' CA PERMIT NO, <br /> Telephone (209) 466-67811 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in-Triplicate) <br /> Application is herebymade tio`the San Joaquin Local 'Health District'for a perm it'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 th an J aquin Local Hea4lsh1 DiD_isxyJjc�ryi <br /> Job Address ,� S6t�d1Vision Name <br /> f Owner's Name <br /> L Address �: Phone <br /> Contractor's Name Z L <br /> 4 ce se No. ������ Phone <br /> 4 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PbMP INSTALLATION j{ SYSTEM REPAIR OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> h: <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED'USE I TYPE OFWELL PROBLEMAREA. CONSTRUCTION SPECIFICATIONS �Yr <br /> IJ Industrial U Open Bottom El Manteca Dia. of'Well Excavation <br /> Domestic/Private Gravel Pack Tracy "" i Dia. 'of Well Casing <br /> N <br /> Public — � Other Delta ♦ ,1_ <br /> Irri at-ion -r Type of Casing". <br /> IJ 9 -- r4pprox:µ«.-�Q-Eastern Spec ifications""`�""�-��� <br /> Cathodic. Protection i Depth <br /> Depth of Grout Seal <br /> Geophysical <br /> r _ Type of Grout¢ � <br /> Wither � p C����� �,• � � Surface SealFlnstalled by <br /> Repair' Work Done Type of Pum x `rs}_,� t State Work Done <br /> h <br /> Well Destruction U Well Diameter Sealing Material (tap 50') <br /> F <br /> Depth l� Filler Material i{Below 50' <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.❑ REPAIR/ADDITION U {No septic tank or seepage pit permitted if public sewer is �} <br /> i available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms ,. �' + Lot siie <br /> Character of sail to a depth of 3 feet: Plater table depth <br /> SEPTIC TANK ❑ Type/Mfg r �`� w' _mk % Capacity, No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg � I fk Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Wel'I.- `"Foundation Property Line <br /> DESTRUCTION 11 <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED U Distance to nearest: Well Foundation Property Line <br /> ,F. <br /> SEEPAGE PITS El Depth Size Number �C <br /> SUMPS LJ Distance to nearest: Well Foundation Property Line p <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work will be doneo n 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 workman�'compensaticn laws of California." <br /> Contractor's hiring or sub7contracting 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 /> l. <br /> The appli t must call fob 1 required inspections. Complete dra /on re se st e. <br /> Signed I Title: „7 �r�G Date: <br /> FOR PARTMENT USE Y <br /> Application Accepte by(�� Area U` L— �Stk 466-678 <br /> Additional Comment Lodi 369-3621 <br /> Pit or Grout Ins ection bT� Date Manteca 823-7104 <br /> Final Inspection by: Date '-�--,�—� ► L7 Tracy 835-6385 <br /> Applicant - Return all copies o: 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 <br /> IIS° C tr-Ig gy gy-1� <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />