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P00n APPLICATION FOR PERMIT <br /> PO\VEL SAN JOAQUiN LOCAL HEALTH DISTRICT p + t <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1'YEAR FROM DATEISSUED <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 /9/0 rt. Subdivision Name 'I <br /> Owner's Name Address f �t./ f�� Phone <br /> Contractor's Name License No. ;3P2 a4 Phone <br /> TYPE OF WELL/PUMP WORK: --SEW WELL -- �WELL REPLACEMENT DESTRUCTION C _ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial U Open Bottom ❑Manteca Dia. of Well Excavation <br /> LI Domestic/Private E]Gravel Pack Tracy .^ Dia. of Well Casing <br /> 17 Public Cj Other _ _[:]Delta Type of Casing <br /> Irrigation .. Approx, Eastern <br /> F, Depth ; Specifications <br /> Q <br /> n Cathodic Protection p Depth of Grout Seal <br /> 0 Geophysical Type of Grout <br /> Other Surface Seal Installed by r <br /> Repair Work Done Type of Pump H.P. State Work Done — O <br /> Well Destruction Cf Well Diameter Sealing Material (top 50') ._ <br /> Depth J. Filler Material (Below 501) <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Cj REPAIR/ADDITION a (No septic tank or seepage�pi2_permitted.ii-publ_ic-sewer is (� <br /> a• available within 206..feet.) <br /> Installation will serve: Residence _ Commercial f Other <br /> Number of living units: Number of'bedrooms Lot sl e '� ' Z <br /> Character of soil to a depth of 3 .feet: yYarWater table depth:; ! 7f- <br /> Op , f <br /> SEPTIC TANK Cj Type/Mfg GA.�w % �Y7y4 Capacity /�B(7 No. Compartments y <br /> PKG. TREATMENT PLT. C] a�. <br /> Type/Mfg - - Capacity Method- 'Oisposal <br /> SEWAGE SYSTEM rj Distance to nearest: Well jge4 'Foundation _fQ14, Prop€rty„Line _9*__ . ?n) <br /> DESTRUCTION SRV <br /> LEACHING LINE (J No. & Length of lines - Total length/size <br /> FILTER BED C Distance to nearest: Well y'• Foundation /Property Line <br /> SEEPAGE PITS DepthSize .365 "+ Numbers 3 / <br /> SUMPS U Distance to nearest: Well 16oundation. Property Line 15r7 <br /> DISPOSAL PONDS ' <br /> i <br /> I hereby certify that I have prepared this application and that the work_wi 14,bgJoM1e in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. , <br /> . Nome owner or licensed agent's signature certifies the=of lowtng;,_,I cert 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 ec6me s61i)ec� o wo Duns compensation laws of California." <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 t call�fa/r�all aired inspect ions. Complete drawing on reverse side. �' <br /> Signed X . f�f/. ��2. . xT+tle:----^_ Date: <br /> F DEPARTMENT USE ILY <br /> - -.-..,..�.---*APpl4aabion-Accepted-by— Area <br /> Add_i tional Comments: Lodi 369-3621 <br /> or Grout Inspection byj —Date b9� Manteca 823-7104 <br /> Final InspeEtiod by - - '----Date Tracy._. 835-6385 <br /> Applicant - Return all copies to: Environmental ealt Permit/Services 1601 E. Hazelton AW P.O. Bax 2009, Stk., CA 95201 <br /> FINFOLA <br /> AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> S <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 3 14-26 _ _ _ <br />