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APPLICATION FOR PERMIT <br /> �1 SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PEI NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED -- IT7� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' <br /> (Complete in Triplicate) <br /> 1 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 Joaqui Local Health District. <br /> Job Address 3 1"*nj Subdivision Name <br /> Owner's Nameddress Phone <br /> } Contractor's Name icense No. Phone <br /> F <br /> TYPE OF WELL/PUMP WORK: NEW,WELL WELL REPLACEMENT DESTRUCTION 1 <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK /100 SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED JSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v <br /> 17 Industrial f-1 Open Bottom ❑Manteca Dia. of Well Excavation i <br /> omestic/Private �avel. Pack Tracy Dia. of,Well Casing <br /> L7 Public [—IOtherDelta Typ/f Casing /.2 S 7ZEZ— <br /> jC1 Irrigation Approx. Eastern <br /> Depth Specifications <br /> Cathodic Protection Depth of Grout Seal _ p ,y <br /> Geophysical Type of Grout _. <br /> Other Surface Seal Installed by L <br /> E Repair Work Done E] Type of Pump !/ H.P. .� State Work Done /rv-S n <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION CJ- (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 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation O - Property Line Z <br /> DESTRUCTION <br /> ` LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS . 71 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS CK <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 shall not employ any person in such manner as to become subject to workmans compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: 111 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 applic us 11 r al it inspections, Complete drawing on reverse side. <br /> Signed x % d Title: Date: <br /> OR WARTMENT USE ONLY <br /> Application Accepted by Area Stk 466-6181 <br /> Additional Comments: Lodi 364-3621 <br /> + Pit or Grout Inspectiv'w"� AW o1 Date „- Manteca 823-7104 <br /> Final Inspection by - Date ' 3;F Tracy 835-6385 <br /> ' <br />