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Q <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-5781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I Application is hereby-made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> 1 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 Sa Joaquin Local Health District. <br /> Job Address 77VSubdivision Name <br /> Owner's Name 47— 4vspez- Address G . e W Phone <br /> Contractor's Name Ane License No, y/., ��/ _ _ Phone <br /> lJ" <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION U ) <br /> f PUMP INSTALLATION SYSTEM REPAIR L] OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.%,,. -_.PROP. LINE d <br /> FOUNDATION AGRICULTURE WELL OTHER WELLl PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation'i• <br /> LJ Domestic/Private. Gravel Pack Tracy Dia. of Well Casing ' <br /> Public G Other Delta Type of Casing <br /> h Irrigation Approx. Eastern Specifications u <br /> Cathodic ProtectionDepth <br /> Yr -^ •° Depth of Grout Seal <br /> 1-1 Geophysical Type of Grout J <br /> LJ Other Surface Seal Installed by f n <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done V <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK:` NEW INSTALLATION U REPAIR/ADDITION L (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 /> a <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> i PKG. TREATMENT PLT. 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 Total length/size <br /> FILTER BED i Distance to nearest: Well Foundation <br /> !Property Line <br /> SEEPAGE PITS � [j Depth Size <br /> Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> -�° DISPOSAL PONDS <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state;laws,,and rulesland 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 /> } P ,f p y erson in-such`+manner as,to become subject to workman compensation laws of California." <br /> I <br /> permit i5 issued,f] shall not�em 1'ii any 'p a <br /> Contractor's hirin or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit i i ed, I shall employ rsons subject to workman's compensation laws of California." <br /> The applica ust call f all red ins a tions. Complete dra g on reverse side. <br /> Signed X , Title: - <br /> Date: i' <br /> D TM ENT U N Y ❑ <br /> Application Aecepted by sr� rea _ tJStk 466-6781 <br /> Additional Comments: Q.Q�� Lodi 369-3621 <br /> 4 Pit or Grout Inspection y Date Manteca 823-1104 <br /> Final Inspection by �' Date T L Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95202 <br /> M FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO �y O 0� Ur, <br /> —�OJO <br /> EH 13-24 REV, 10/82 ' 10/82 500 <br /> 14-26 Oz— l ' -),S`1(� <br />