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i APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT a� ' <br /> x 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.x <br /> Telephone (209) 466-6781 IM <br /> DATE ISSUED <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 t San Joaquin oval Health District. k <br /> Job Address fl p 4 Subdivision Name II <br /> wner's Name � dress ` Phone <br /> Contractor's--Name ' License No. f0 Phone 721 <br /> TYPE 4f W �MP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ? <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Ik <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I� <br /> 'I <br /> INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS <br /> 17 Industrial U Open Bottom Manteca Dia. of Well Excavation I <br /> Domestic/Private Gravel Pack [ Tracy Dia. of Well Casing k <br /> i <br /> P �J Other Delta Type of Casing <br /> Irrigation Approx. Eastern Specifications <br /> a o is Protection DepthLl ; <br /> Depth of Grout Seal !� <br /> Geophysical I � <br /> Type of Grout <br /> F1 Other _ Surface Seal Installed by M <br /> Repair Work Done EJ Type of Pump H.P. State Work Done �N ' <br /> I Well Destruction j Well Diameter -77—j7— <br /> iameter Sealing Material (top 50') , <br /> Depth Filler Material (Below 50')571 g <br /> AUNK W. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 2 0 feet.) G <br /> Installation will serve: Residence Commercial T Other <br /> k Number of living units: .. Number of bedrooms Lot size I <br /> Character of soil to a depth of 3 feet: Water table depth j <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments IM <br /> PKG. TREATMENT PLT. f] Type/Mfg Capacity Method of Disposal :M <br /> Distance to nearest: Well Foundation Property Line I� <br /> 'k <br /> LEACHING LINE U No. & Length of lines Total length/size r <br /> FILTER BED Distance to nearest: Well Foundation Property Line k <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ II� <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 workman§compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the fallowing: "I certify that in the performance of the work for which <br /> thispermit is ued, I shall y p sons subject to workman''s compensation laws of California." <br /> The applican t call for I equi d inspecti ns. Complete draw on reverse side. <br /> Signe TitleL, Date; pf� <br /> FOR DEPARTMENT OSLY 0 �p <br /> Application Acc ted by 16 Area Stk 466-6781- <br /> Additional Comments: Lodi 369-3621 <br /> I <br /> Pit or Grout Inspection bDate Manteca 823-71,04 <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant - Return all copies to; Envi4nm;ntai 4effth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S4., CA 95201 <br /> I I <br /> FEE SASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> C1 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> F 14-26 <br />