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Al <br /> APPLICATICN FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Q�A L <br /> 1601 E. HAZELTON AVE., STCCKTON,' CA PERMIT N0. - B = <br /> Telephone (209) 466-6781 <br /> p PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Regula ions U9f, the Sn Joaquin Lora ealth District. <br /> Job Address i/- 1. <br /> Subdivision Name <br /> Owner's Namet9 Address Phone 3 $ q <br /> Contractor's Name ' License No. Phone <br /> dc)1 011 4 <br /> TYPE OF WELL./PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION [ V t/`1 <br /> PUMP INSTA"L_LAT��N �' SYSTEM REPAIR OTHER [J- <br /> L <br /> DISTANCE TO NEAREST: SEPTIC TANK � /1 { SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION T AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION'S " L <br /> Industrial [J- Open Bottom E Manteca Dia. of Well Excavation Q fr <br /> !a <br /> 'Domestic/Private [r�"GraveT Pack ❑ Tracy Dia, of Well Casing rt <br /> Public [ Other Delta <br /> Irrigation f Type of Casing <br /> Li 9 �O Approx. Eastern Specifications <br /> r �� <br /> [ Cathodic Protection Depth p <br /> 17 Geophysical <br /> Depth of Grout Seal } <br /> lr' <br /> E} U Other Type of Grout € <br /> ��yy Surface Seal Installed by <br /> Repair Work Done [] Type of Pump SGLd H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) <br /> 1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ REPAIR/,40DITION J (No septic tank or seepage pit permitted if public sewer is <br /> 1 <br /> Installation will serve: Residenceavailable within 200 feet.)` Commercial Other i <br /> Numben,of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK <br /> � Type/Mfg g Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ <br /> LEACHING LINE [J No., & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well 'Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> R <br /> SUMPS Cj Distance 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 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, T shall not employ any person in such manner as to become subject to workman5 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 shall employ persons subject to workman's compensation laws of California." <br /> The appli mus call for all r red pecti s. Complete drawing o reverse side. <br /> Signed X Title: _ Date: V i <br /> � OR PAybg T USE ONLY <br /> pplication Accepted y Are Qy 5tk466-67 <br /> dditional Comments: �� ' f " Lodi 369-3621 <br /> Pit or Grout Inspection b Date 7-6—j?? ✓ Manteca 823-7104 <br /> Final Inspection by -Date L'2;2.7. ❑ Tracy 835-6385 w <br /> Applicant - Return all copies to: . Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' <br /> FEE $ASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO i <br /> 9 G y <br /> EH 13-24 REV. 10/82 10/82 50p <br /> c <br /> ' 14-26 8 ZS �i�fo � . <br />