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a <br /> APPLICATION FOR PERMIT <br /> SAN .OAQUIN LOCAL HEALTH DISTRICT <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 San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> described. This applz•eation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules ridgRei of the SaJoaquin ocalalth District. <br /> Job Address J �llll.JJ.. Subdivision Name <br /> Owner's Name Address Q Li Phone <br /> Contractor's NamT? Gd License',No. Phone (W­ <br /> TYPE <br /> t s� <br /> 6 <br /> f <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR jam; OTHER ❑ r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES (DISPOSAL FLO. - PROP. LINE W <br /> FOUNDATION 1 AGRICULTURE WELL ' OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial Lj Open Bottom [] Manteca Dia. of Well Excavation -- <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing <br /> ❑ Public ;�❑ Other ❑ Delta Type of Casing <br /> J ❑ Irrigation Approx. Eastern' Specifications <br /> Cathodic Protection Depth <br /> ❑ Depth of Grout Seal <br /> �❑Geophysical Type of Grout } <br /> ❑Other Surface Seal Installed by t <br /> Repair Work Done ❑ Type of Pump f N.P. State Work Done <br /> Well Des truction.LJ Well Diameter.) Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION. ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> ava.i.lable within 200 feet.) <br /> Installation will serve: Residence' <br /> Y Commercial �O7ther F r 1 <br /> Number of living units: y Number of=rc6��� Lot size Character of soil to a depth of 3'feetWater table depth # <br /> SEPTIC TANK ❑ Type/Mfg Capacity ?No. C6mpartments _ # <br /> ,� <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Dis posal <br /> SEWAGE SYSTEM Distance to nearest: Well - Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE ❑" No. & Length of lines Total length/size` <br /> FILTER BED Distancekto nearest: �Wel11­� Foundation `P/roperty Line <br /> SEEPAGE PITS Depth / _` Size Number / - s <br /> z ` _S <br /> SUMPS Distance to nearest: Welliy�_ Foundation /[) _ 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 1 ¢ <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.r <br /> such manner as;�to,becow6 subject to workman compensation laws of California: ( <br /> ' <br /> permit is issued, I shall not employ any person a <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 IF all required inspections. Complete drawing on reverse side, o? '� " <br /> Signed X Title: 11, Date: <br /> FOR DEP TMENT USE ONLY ❑ f'F <br /> Application ACcepted' by Z v Area - Stk 4b6-6781 <br /> Additional Comments:-+ Lodi 369-3621 <br /> Date Manteca 8237104 <br /> Pit or Grout InspectiAtE`4nv6rnT,.n&ti11,H,,ltih <br /> ❑ f <br /> Final Inspection by Date ❑ Tracy /835-6385 <br /> Applicant - Return all topic Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009 St k., CA 95201 <br /> _ - f <br /> =� B AMOUNT DUE AMOUNT REMITTED-'^ DECEIVED BY �OATE PERMIT NO. <br /> I <br /> L 10/82 500 <br /> FH 13-24 REV. 10/82 l „• �� <br /> 14-26 <br />