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t a 6 <br /> ' APPLICATION FOR..PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT NO. i <br /> Telephone (209) 466-6781 s R DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' <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 arl Joaquin Local lth District. <br /> Job Address r O"f Z ubdivision Nags �y <br /> 1 a / Phone g�fr 15 <br /> s l r <br /> Owner's Name Phone <br /> Contractor's Nam < <� License No. <br /> WELL ,WELL REPLACEMENT-[� DESTRUCTION F1 w <br /> TYPE OF_wELL/PUMP NEW WORK: �;CO <br /> PUMP INSTALLATION (�" " SYSTEM REPAIR OTHER LJ4l <br /> �S�iIER L1NE5 _DISPOSAL FLC� PROP, LINE <br /> DISTANCE'TO NEAREST:-S-EPTiC'TANk-'� - OTHER WELL PITS/SUMPS r <br /> FOUNDATION AGRICULTURE WELL r <br /> IPROBLEM AREA CONSTRUCTION SPECIFICATIONS Q� <br /> 4INTENDED USE TYPE <br /> OF WELL 1 <br /> Dia. of Well Excavation — <br /> I�Industrial j JOpen Bottom ❑Manteca — <br /> Dia. of Well Casing <br /> DomesticlPri-vate•.: .--Gravel f Pack- ` Tracy <br /> Y <br /> Public Other-r,-A []-Delta Type of Casing <br /> ` LJ Irrigation " Depthx Ea4tern Specifications <br /> Cathodic, Prot ection' ^ Depth of Grout Seal <br /> A { Typtof Grout <br /> u Geophysical ,.� <br /> Surface Seal Installxd by <br /> { []'Other ` .. •, 1 — — <br /> 1{Ia of Pump H.P. State Work Done <br /> Repair Work Done � 1 <br /> Type <br /> Well Destruction U Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> --... available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U PAIR/AC0ITION No septic tank or seepage pit permitted if, public sewer is <br /> ther —v- <br /> installation will serve: Residence , Commercia Lot size <br /> Number of living units: Number of b rooms Water table depth <br /> Character of soil to a depth of 3 feet: No Compartments <br /> •:T >'JMf .+; ��_• _ <br /> city, <br /> -,!,,"SEPTIC TANK � Yp. 9i y `Method�df Disposal __�!— <br /> ' * _*'�'J;� rt. �. Capacity <br /> PKG.�G. TREATMENT PLT. Type/Mfg — ` <br /> �' Foundation,t Property Line y <br /> "_SEWAGE SYSTEM Distance nesaresst: Well <br /> DESTRUCTION% ^� <br /> Total 1 ngth/size d <br /> I LEACHING LINE No..& Length of lines _�� - �f g ert Line ` <br /> 1 Foundation .c Prop Y �. <br /> FILTER BED [� Distance to nearest: Well ©8 <br /> Depth __ — Size Number <br /> SEEPAGE PITS G <br /> SUMPS j� Distance to nearest: Well Foundation Property Line <br /> j DISPOSAL PONDS CI �s <br /> E I hereby certify that I hnderulesared regulations of then anhJoaquenwLodal-Healthork will be dDistrictccoriianc� with San Joaquin county <br /> or which this <br /> ordinances, state laws, a ' <br /> Home owner or licensed agent's signature cersonrin such`.11 mannernas to becomeysubiectntohworrkkmank compensatance of honwlawsork fof California."i <br /> permit is issued, I shall not employ any p <br /> Contractor's <br /> ihiring <br /> eo Iushalltemploygpsignature <br /> ersons certifies <br /> subject the <br /> following: "I ce <br /> compensation ofaCal�ifornithe aerformance of the work for which <br /> this permit <br /> The applic must call fo all required inspecti S. Complete drawing on reverse side. Date: _ <br /> t Title: -- -- <br /> Signed X <br /> DEPARTMENT USE ONLY 0 Stk 466-6Y159*- <br /> FOR <br /> Area _ <br /> l Application Accepted y _ 0 Lodi 369-3621 <br /> Additional Comments: Date — Manteca 823-7104 <br /> Pit or Grout Inspection by flats L Tracy 835-6385 <br /> Final Inspection by <br /> t — <br /> Applicant - Return all copies to: Environ l Health Permit/Services 1601 E. Haaelton Av ., P.O. Box 2009, Stk., CA 95201 <br /> RECEIVED BY < DATE PERMIT NO. <br /> FEEBASE MOUNT DUE AMOUNT REMITTED <br /> INFO <br /> 10/82 500 <br /> LH 13-24 REV. 10/82 <br /> 14-26 <br />