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y APPLICATION FOR PERMIT b �� <br /> u . SAN JOAQUIN`LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE-, STOCKTON, CA PERMIT NO. <br /> Telephone (Z09) 466-6781 - ---� <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> a (Complete in Triplicate) " <br /> Application is hereby made to the~;San Joaquin Local Health District for at permittoconstruct and/or install. the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 544 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin cal Health District. <br /> Job Address3� Subdivision Name - `►4J,�z <br /> Owner's Name Addre s Phone1 10 <br /> Contractor's Nam A i License No. � �� Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT Q DESTRUCTION Q <br /> I PUMP INSTALLATION Q SYSTEM REPAIR Q OTHER Q <br /> DISTANCE TO NEAREST: SEPTIC TANK dl SEWER LINES DISPOSAL FLD. PROP. LINE . <br /> FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE iOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> industrial Q Open Bottom Q Manteca Dia. of Well Excavation <br /> Q Domestic/Private Q Gravel Pack Cj Tracy Dia. of Well Casing <br /> Public <br /> l� f Other Q Delta:�1 <br /> Irri ation �� <br /> Type of Casing <br /> U 9 Approx. [] Eastern ' Specifications <br /> Q Cathodic Protection Depth — <br /> Q Geophysical Depth of Grout Seal <br /> Q Other Type of Grout / 1 <br /> Surface Seal Installed by f, <br /> Wel l!Destruction {_J Well Diameter Sealing Material (top <br /> Depth Filler Material (Below 50') i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION �J (No septic tank or seepage pit permitted if public sewer is i <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other 1 <br /> NUmber of,"l'ivfng unitf:-T"PNUmber 6f'b{drooms Lot size I <br /> CFtaracter'.of soil to 1--depth of.,9-)feet•" D _, Water table depth <br /> SEPTIC TANKI Type/Mfg � � 14acj` y'. No. Compartments <br /> PKG.' TREATMENT PLT. ]--"'Type/Mfg�l i > Capacity-��1 G0•Q•- -Method of Disposal <br /> SEWAGE SYSTEM ­-Diatance to nearest: Well k Foundation", Line ik <br /> t ?, tDESTRUCTION Q ;;` i ; ,-- �_ f. �. —• _ <br /> LEACHING LINE No. & Length of lines c '"��J(j c(Total length/size <br /> t <br /> FILTER BED Distance to nearest; Well Foundation - Property Line I r <br /> 'SEEPAGE PITS Q DepthSize Number <br /> E� <br /> x.SUMPS j] Distance` to nearest: i1e1Y.1 Foundation Property Line <br /> r,10ISPOSAL PONDS - <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance withiSan 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 workmank 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 shait.employpersonsiiubject to,workman,s._compen sat ion laws of California." <br /> _ i <br /> The applicant must ca f 1 r fired inspections'. CompleteGdrawirig on reverse side. <br /> Signed % '� � s Tit e . .l`. �` ' I Date: <br /> F R DEPARTMENT USE_ONLY,.,,.,r_._._ j <br /> f Application Accepted by Area -�^ ~ + Q Stk I 466-6781 <br /> Additional Comments: .1� I J [J Lodi 369-3621 <br /> i <br /> Pit or Grout Inspection by!1 Date ; ' U Manteca 823-7104 <br /> Final Inspection by I _ _ Date , TS <br /> U�}^ Tracy; 835-6385 <br /> e <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P_-O_ Box 2009, Stk., CA 95201 <br /> j <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY 1 DATE PERMIT NO. <br /> i INFO <br /> EH 13-24 k&V. 10/82 10/82 500 <br /> 14-26 <br />