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APPLICATION FOR PERMIT <br /> SAN JOAQLia LOCAL HEALTH DISTRICT y4^Y> <br /> 1601 E. HAZELTON AVE., STOCKTON. CA PERMIT NO. <br /> 3". Telephone (209) 466-6781 <br /> p DATE ISSUED CA ' <br /> } .' .. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED VJ <br /> (Complete in Triplicate) 1 <br /> , <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> �•,.ri described. This application is made in compliance wit San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wellXDumpCA <br /> and the Rules6nd REel <br /> ulat on the an Joaqu' Loca Health i i�t.l <br /> Job Adores <br /> lSuJtslorT RaOwner's Name _Contractor's NaLicense No. - Phone <br /> T} TYPE OF WELL/P'.�MP WORK: NEW WELL WELL REPLACEMENT [1] DESTRUCTION G <br /> " PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FCD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> l�. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑Industrial 1­1 Open Bottom 0 Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia. of Well Casing a <br /> Public [jOther ❑Delta Type of Casing <br /> [j Irrigation Approx. [Eastern Specifications <br /> Cathodic Protection Depth <br /> 33 Depth of Grout Seal <br /> 7 Geophysical Type of Grout <br /> 191 <br /> 1­1Other Surface Seal Installed by <br /> Repair-Work Done Type cf Pump H.P. State Work Done ,� . <br /> • � Well Destruction[] Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK:, NEW INSTALLATION LI REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is •,tiQ-. <br /> available within 200 feet.) <br /> Installation will.serve: sidence _� Commercial _ ther ro! <br /> Number of livinn, units: Number of bedrooms Lot size <br /> • <br /> y Water table depth fir, <br /> Character of soil to a dept of 3 feat: <br /> e No. Compartments <br /> T Mf � • <br /> SEPTIC TANK ❑ Type/Mfg/ 9 Capacity <br /> Capacity Method of Disposal <br /> PKG. TREATMENT PLT. Type/Mfg <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION t r , <br /> Total length/sire <br /> LEACHING LINE No. b Length of lines <br /> i FILTER BED ] Distance to nearest: Well Foundation Property Line <br /> rNumber <br /> SEEPAGE PI75 Depth Size <br /> 1. SUMPS LJ <br /> Distance to nearest: Well Foundation Property Line <br /> 1s <br /> •� DISPOSAL PONDS s <br /> 1 hereby certify that I have prepared this application and that the work >> he done in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local uea !h District. <br /> r' Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> any person in such manner as to become subject to workmant compensation laws of California <br /> permit is issued, 1 shall not employ ." <br /> ! Contractor's hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for which <br /> this <br /> Contractor <br /> permtis is ed, ! s 11 employ persons suaject to workman's compensation laws of California." <br /> ns actions. Complete dr wing on eveTse sl <br /> e. <br /> The app ust c 1 f all R•yu D --- �- 1 Dat s <br /> • <br /> Sig Title: <br /> H I ) F P FAT USE Oy Stk 466-6781 <br /> %.. Application Accepted by a '• <br /> Additional Comments: Lo <br /> 368-3621 <br /> Date �� /�r�-'—//, 17 Manteca 823-7104 <br /> p Pit or Grout:Inspection 1 t 'l ,3 �I Tracy 835-6385 <br /> rh' Final Inspection by y�Date U <br /> t Applicant - Return all copies Environmental Health Permit/Services 1601 E. Ha elton Ave., i-.O, Box 2009, Stk., CA 95201 <br /> P rIN <br /> BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE P'P,MIT N0. <br /> ..i. <br /> a Z{$• W gtS <br /> 10/82 500 <br /> -EH 13-24 REV. 10/82 <br /> r 14-26 <br />