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APPLICATION FOR PERMIT f� <br /> SAN JOAQUiN LOCAL H2ALTH DISTRICT p <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - <br /> (Complete in Triplicate) <br /> Application_is'•hereby made to the Sari Joaquin Local Health District for a permit to construct and/or install the work herein !f <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump t <br /> and the Rules and Re ulat}ion�s/o/f t 5 r Joaquin Lecal h is riot. 14 <br /> Jab Address i W & � Subd Psion Name �� <br /> Owner's Name ��° a t dress � 0` I y ' ' <br /> Phone <br /> Contractor's NaW- A �'(JT License No. 1 Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ] WELL REPLACEMENT ❑ DESTRUCTION ❑ ) <br /> PUMP INSTALLATION• SYSTEM REPAIR LJ OTHER-(J _ t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE5 DISPOSAL FL_.D PROP. LINE✓` <br /> FOUNDATION AGRICULTURE WELL OTHER WELL' ` PITS/SUMPS J <br /> INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ] Industrial L Open Bottom E]Manteca t ; Dia. of Well Excavation _ <br /> Domestic/Private Gravel Pack_ C1 Tracy _Dia. of Well Casing i <br /> Public L Other Delta i <br /> j Irrigation - _Approx. ]Eastern Type of Casing <br /> Depth Specifications /1 . <br /> [J Cathodic Protection l <br /> ]Geophysical Depth of Grout Seal <br /> r- <br /> r"'i s, (O <br /> Other � �• _ �Y. Type of Grout � <br /> Surface Seal Installed by '� f (b <br /> Repair Work Done ] Type of-Pump----�-•H:P.- -4.+-•• State-Work Done <br /> Well Destruction ] Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501`� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION .REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other - <br /> Number of living units: J_ Number`.of bedrooms Lot size 117 2-, <br /> Character of soil to a depth of 3 feet: Nater table depth <br /> SEPTIC TANK Type/Mfg �; Capacity i o `-f:No. Compartments { <br /> PKG. TREATMENT PLT. ] Type/Mfg f Capacity __, Method of Disposal <br /> SEWAGE SYSTEMDistance to nearest: Well ` Foundation Property Line, LLT <br /> DESTRUCTION C] S, -- <br /> LEACHING LINE '� No. &'Length of lines E__Q0 O A Total length/size - <br /> FILTER BED Distance to nearest: Well Foundation .Property Line 1 <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation J Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San 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'snall not employ an ersatonre in such manner as to become subject to workman§compensation laws of California." <br /> Contractor's hiring or sub-contracting -nucertifies the following: "I certify that in the performance of the work for which <br /> this permit is issued. I shal a oy p s ns subject to workman's compensation laws of California." <br /> The ap .Mpections. Complete drawing on reverse side. <br /> Signed Title: Q�/ Cr _Date: <br /> 0 DEPARTMENT S 14LY S fyI <br /> Application Accept by _ _Area -/ 07 ] Stk X66 6781 <br /> i <br /> Additional Comments: _ Lodi 369-3621 <br /> Pit or Grout Inspection by Date _ Manteca 823-71A4 <br /> Final Inspection by -�5�Z1 +_�/ Date 7 -Tracy 835-6385.AAA kC_ <br /> Applicant - Return all copies- <br /> opies to: Envi ntal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ! <br /> FEE ( BASE AMOUNT,. DUE AMOUNT RE14ITTED RECEIVED BY DATE 'PERMIT"NO. <br /> INFO .: — .. <br /> 5-11 <br /> 4.. EH 13-24- REV. 10/82 �� F , 10/82 500 1 <br /> .14-26 <br />