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••N' APPLICATION FOR PERMIT <br /> ?+ SAN JOAQUIN LOCAL HEALTHDISTRICT 'g 3 PERMIT N0. 15 3 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> • � _ ,a f Telephone (209) 466-6781 ' DATE ISSUE,,? <br /> �•'•✓' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> - _.,�• <br /> (Complete in Triplicate) <br /> -Application is hereby made;,to�'the San Joaquin Local Health District fora permit to construct and/or install the work herein <br /> n Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> described. This applicat'i'on is made in compliance with Sa <br /> and the Rules and Regulations of the San Joaquin Lohal Health District.,, � /Ya <br /> Job Address „ IO-yrO� /�1 2 Or 7I 47tf �+ Subdivision Name <br /> !!'. Address. .{� Phne <br /> Owner's Name rS t1. Phone 444 9 /76 <br /> Contractor's Na AW�Ns�6YS -�— License No.- <br /> ' TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION CJ <br /> PUMP INSTALLATION ® SYSTEM REPAIR OTHER 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP. LINE — <br /> FOUNDATION AGRICULTURE WELL, OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA •�, CONSTRUCTION SPECIFICATIONS U <br /> Industrial (J Open Bottom E]Manteca Dia. of Well Excavation <br /> Domestic/Private F1 Gravel Pack ❑Tracy Dia. of Well Casing - <br /> L7 Public ❑Other ❑Delta Type of Casing <br /> Lj Irrigation - Approx. Eastern Specifications <br /> ' ❑Cathodic Protection Depth t Depth of Grout Seal <br /> Geophysical # Type of Grout <br /> Ocher Surface Seal Installed by <br /> Repair Work Done® Type•of Pump St� H.P• State Work Done C <br /> Well Destruction ❑ Wel I.i Diameter Sealing Material. (top 501) <br /> Depth Filler Material (Below 50') _ V <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Fl REPAIR/ADDITION U (No septic tank or seepage pit ilableewithinu200c feet.) is ` <br /> ' Installation will serve: Residence _ Commercial _ Other , <br /> Number of living units: Number of bedroomsLot size <br /> ' Character of soil to a depth of 3 feet: •� Water table depth <br /> • Type/Mfg .Capac`¢y, :. No. Compartments <br /> SEPTIC TANK , Method of Disposal <br /> PKG. TREATMENT PLT. � ` Type/Mfg Capacity . _ ..,. <br /> SEWAGE SYSTEM Distance to nearest: We11 - -` Foundation <br /> Property Line <br /> DESTRUCTION Clp ^, ' <br /> length/size <br /> leng <br /> LEACHING LINE U � No. & Length of lines TotaProperty Line <br /> FILTER BED a Distance to nearest: Well F6undation- <br /> Depth Size o Number . <br /> SEEPAGE PITS property Line <br /> SUMPS LJ Distance to nearest: Well F;undation <br /> DISPOSAL PONDS <br /> I hereby certify that i have prepared this„appl.ication and that the Z;rk will be done in accordance`with San Joaquin county <br /> ordinances, state that <br /> have <br /> rules and regulations of the San"JoaquintLocal Heal-th-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 workmanh 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 must call for al r u ins.Qecti s. Complete drawing on reverse side. Date: <br /> Signed X '{ Title: �rge <br /> J DE WENT USE LYStk 466-6781 <br /> Application Ace Led b r <br /> Lodi 369-3621 <br /> Additional Comments: Date Manteca 823-7104 <br /> Pit or Grout Inspecti b Date Tracy 835-6385 <br /> Final Inspection`by p,0. Box 2009, Stk., CA 95201 <br /> Applicant - Return all copie nvironmental Health Permit/Services 1601 E. Hazelton Ave.. <br /> ' FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE.p _?PERMICT N0. <br /> INFO , `S 3 '.S 0_3 <br /> �J- �✓ .3 <br /> C.-� 10/82 500 <br /> ' EH 13-24 REV. 10/82 e r f <br /> 14-26 e <br />