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f APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT k <br /> 1501 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 PERMIT N0. <br /> A PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> • i1 <br /> (Complete:in Triplicate) <br /> • ti <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,appl!cation is made in compliance with San Joaquin County Ordinance Na, 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Hea,JtQh'D�' ct. <br /> Job Addiess 7 ,�, f} % �F6 fTvisicn Name <br /> Owner's Name Address <br /> Phone <br /> Contractor's Name L `e se <br /> Al- <br /> Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT _ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR Li OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F-1 U Open BottomManteca <br /> ❑ Dia. of Well Excavation <br /> U Domestic/Private Gravel Packrac t <br /> ❑ Tracy Dia. of Well Casing <br /> Public <br /> Ej Other ❑ Delta <br /> Lj Irrigation A Type of Casing i <br /> Approx. �Eastern <br /> Cathodic Protection Oe Wl Specifications <br /> Geophysical Depth of Grout Seal! <br /> ❑Other Type of Grout <br /> Surface Seal Installed by 1 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 5C1) <br /> f Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONfREPAIR/,ADDITION J (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence Commercial _ Other vailable within 200 feet, d <br /> Number of living units: Number of bedrooms Lot size <br /> �E Zv�44� VWA sr <br /> `• 2 Llndss , 9 <br /> Character ofsoilto a depth of 3 feet: Water table depth I <br /> SEPTIC TANK Type/Mfg Capacity INo. CompartmentsT <br /> PKG. TREATMENT PLT. Type/Mfg <br /> Capacity � Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well � T__�— ! <br /> DESTRUCTION ❑ �Z Foundation _10 property Line <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BEDProperty Line <br /> Distance to nearest: Well Foundation J 6 "" <br /> ,3,j <br /> SEEPAGE PITSNI' Distance <br /> Depth '26xNumber 3 <br /> SUMPS to nearest: Well � 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,J 1 quin 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 employany person in such manner as to become subject to workman.t_compensation laws of ,California." <br /> Contractor's hi-ring or sub-contracti signature certifies the following: "I certify that in the performance of the work for which <br /> this permit ed, I shall empl persons subject to workman's;compensation laws of California." <br /> The appl'cant m t all r 11 re r d in ctions, Complete dra - - ` <br /> y e� p r g on reverse side. _ - <br /> Signed-•X Title: I Date: 3 p w <br /> OR RTMENT US �j <br /> Application Accepted-by rea St 466-6781 <br /> RdditionaT Comments: " T <br /> J>CLodi 369-3621 <br /> Pit or Grout Inspection byN C r a e <br /> Manteca 823-7104 <br /> Final Inspection by1 Date <br /> • ��-�( ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave0. Box 2009, Stk., CA 95201 <br /> - y:7 <br /> FEF BASE AMOUNT DUE AMOUNT REMITTED . 4 RECEIVED BY DATE PERMIT N0.' <br /> INF D <br /> � <br /> EH 13-24 REV. 10/82 ~ 10/82 500 " <br /> 14-26 <br />