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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> - Telephone (209) 466-6781 <br /> DATE ISSUED A <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 San Joaquin Local Health District. <br /> Job Address Ido© WM7/� j Aol a Subdivision Name <br /> Owner's Name WF L4 WAXjC—" Atp Address Phon <br /> Contractor's Name License No. Phon <br /> —�-1—v Wr <br /> TYPE OF WELL/PUMP WORK: i NEW WELL Q WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> LFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 71 Industrial L Open Bottom ❑ Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> ❑ Public L Other Delta <br /> Type of Casing <br /> LjIrrigation Approx. ❑ Eastern <br /> Cathodic Protection Depth Specifications <br /> Depth.of.Grout Seal <br /> Geophysical <br /> Other ' Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Dane ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> -- Depth ° Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION E (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: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK EW-,-'Type/Mfg L Capacity 2,0-0 No. Compartments <br /> PKG. TREATMENT PLT. L Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ <br /> LEACHING LINE No, & Length of lines Z S f __- Total length/size r <br /> FILTER BED Distance to nearest: Well Foundation /®0 Property Line <br /> SEEPAGE PITS Depth - � Size Number ]ter + ! <br /> � r <br /> SUMPS Distance to nearest: ell Foundation #' Property Line" <br /> DISPOSAL PONDS 0. <br /> I hereby certify that I have prepared this application and that the work will be done in accor ce with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health.District. v <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's compensation laws of California." <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 shat em lay per ons subject to workman's compensation laws of California <br /> The app}ic 7 <br /> ca inspections. Complete drawing on reverse side. X + <br /> SignelX Title: 92 5.d&ffta_, <br /> Date: <br /> FOR DEPARTMENT USE ONLY '7 <br /> plication Accepted by Area )2, 466-6781 <br /> Additional Comments: f [] Lodi *369-3621 <br /> Pit or Grout Inspection b Date Manteca 823-7104 <br /> Final Inspection by Cate5 Tracy 835-6385 <br /> Applicant - Return all copies E 7r nmental Health Permit/Services 1601 E. Hazelton, P.D. Box 2009, Stk., CA 95201 <br /> FTNFO <br /> BASE AMOUNT DUE AMOUNT REMITTED 'RECEIVED BY DATE PERMIT N0. <br /> EH 13-24 REV. 10/82 vv — <br /> 10/82 500 <br /> 14-26 -�_ L+C <br />