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APPLICATION FOR PERMIT / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT a <br /> it 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 0- 3-�4 �3 <br /> Telephone (209) 466-6781 f <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 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 SanJoaquin Pcal Health District. <br /> f Job Address Uud. 65ubdi.vision Name <br /> Owner's NameAddress , jj ►- �/ �/p Phone <br /> Contractor's Name t[ �00 License No. 1ql Phone '13OT-10S— <br /> TYPE OF WELL./PUMP WORK; f NEW WELL E] WELL REPLACEMENT DESTRUCTION ❑ <br /> " PUMP INSTALLATION SYSTEM REPAIR OTHER � . <br /> d DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP$ <br />` <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I <br /> 17 Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private El Gravel Pack - E]Tracy Dia. of Well Casing <br /> Public ]Other Delta Type of Casing <br /> LjIrrigationY Approx. Eastern <br /> Depth � Specifications <br /> Cathodic Protection p <br /> Depth of Grout Seal <br /> Geophysical <br /> i ]Other ; t: ., ,L<Type of Grout,v <br /> - -K.Surface-Seal,InstalTed-by-- — - <br /> Repair Work Dane ❑ Type of Pump H.P. State Work Done <br /> Well Destructi <br /> on (J Well Diameter _ Sealing Material (top 501) <br /> Depth Fil-ler`Material.-(Below 50') 411 <br /> TYPE OF SEPTI€ WDRKi: NEW'INSTALLAT•fON U EPAI .ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will ser roe: Residence YV Commer'' <br /> spa]_ Other <br /> Number of lavin units: Number of b dr <br /> 9 ooms � Lot size <br /> Character of soil to a depth of 3 feet: Water table depth L <br /> h SEPTIC TANK Type/Mfg , Capacity No. Compartments <br /> �•J r _ <br /> PKG. TREATMENT PLT. � Type/Mfg ;,;. � 'rr� Capacity Methad. of Disposal <br /> y # Distance to nearest: `Well -Foundation' Property Line (� <br /> LEACHING LINE No. & Length of lines _ '# 'r' <br /> �^ <br /> 9 � -'_�10 Total length/size <br /> FILTER BEDS Distance to nearest; Well Foundati6n­/-0 Property Line �y <br /> I <br /> SEEPAGEe'PITS [] Depth Size ' Number <br /> SUMPS 1J Distance to nearest: Well Foundation Property Line <br /> DISPOSALS PONDS <br /> I hereby certify that I have prepared this application and that4 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 shall not employ any person in such manner as to become subject to workman k compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in h <br /> 9 y the performance of the work for which <br /> this permit is issued, 1 shall emoy per _o4 <br /> sons subject _workman!s compensation laws of California." <br /> The appl <br /> plicantust call fo all required inspections. Complete drawing o reverse side. <br /> r1V <br /> Signed X �,`,�.Q I4a'�.*1M Titae:`^; Date:/') . <br /> �._ R _. „r FO EPARTMENT USE-ON Y_.-,s <br /> Application Accepted by Area F-1 Stk 466-6781 <br /> Additional Comments: � Lodi 369-3621 <br /> Pit or-Grout—Inspect-ion-by Manteca 823-7104— <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant - Return all copies Ab. Environmental Hea th Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> ay 3-y13 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />