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APPLICATION FOR PERMIT " <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> 1601 E. HAZELf6N AVE., STOCKTON, CA PERMIT NO. - <br /> Telephone (209) 466-6781 <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 -a-nd Regulation f the San Joaqui ocal Health District. <br /> Job Address / � M Subdivision Name" <br /> Owner's Name Address Phone <br /> Contractor's Name EL. �, L` License No. Phone , <br /> TYPE OF WELL/PUMP WORK: NEW WELL �] WELL-REPLACEMENT b .x-.14 TRUCTION <br /> 4 _ PUMP INSTALLATIOiJ [] SYSTEM REPAIR_[ 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.QF-WELL -PROBLEM-AREA. CONSTRUCTION SPECIFICATIONS <br /> 4 <br /> Industrial ❑ Open Bottom Manteca Dia. of.Well Excavation <br /> ! Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> L� Public [j Other Delta <br /> Irrigation Type of Casing <br /> LI 9 Approx. [�Eastern Specifications.- --� <br /> Cathodic Protection Depth """" ' <br /> t Depth of Grou#:Seal <br /> Geophysical F <br /> i r .�: Type of Grouts ., <br /> U Other s a: Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump 'H.P. State Work Done <br /> Well Destruction [—I Well Diameter ' .-,-Sealing Material (top 50') <br /> Depth + " Filler Material (Below 50') <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t`��.T REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer -is <br /> t available within 200'feet.) W - <br /> Installation will serve: Residence - Commercial Other <br /> i Number of living .units: �- _ Numbe sof bedrooms �3 ;2, 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 ,.,.moi; Capacity Method. of Disposal ' <br /> . �. Distance to nearest: Well Foundation Property.Line" <br /> LEACHING. LINE No. &Length of�.)ines * Total length/size .. ., <br /> FILTER, BED Distance o.nearest: Well Foundation Property Line <br /> SEEPAGE PITS -' Depth Size Number �. <br /> SUMPS Lj Distance, to nearest: Weil Foundation .Pro'perty LineII <br /> F j <br /> ' DISPOSAL PONDS ,p J• ,D <br /> " I hereby cert 1';fy that I have prepared,this application and that the work will be;done in accordance-with San Joaquin county <br /> ordinances,=rs$ate laws, and rules and regulations of the San Joaquin Local Heal•th(-D.istrict. -= <br /> 1 Home owner or;licensed agent's signature certifies the following: "I certify that iri,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 /> Cont ctor:s'hiring or sub-contracting signature certifies the <br /> ,following.- "I certify that in the performance of the work for which <br /> this p 1 is issued, I shall employ persons subject to workman's compensation laws of California." <br /> Thea lic st c I o 11 r Ii in s.�tions: Com l�te�dr 'in q r verse side. <br /> Signed p� Titpe: g i i / µ� Date: ~ <br /> FOR DEPARTMENT USE ONLY a - / <br /> J"a) iii°° <br /> Application Accepted by r� f . -r s-Y Area [ Stk 465x6781 <br /> Additional-Comments: /5. r-`t! Lodi' 369-3621 ` <br /> Pit or Grout••Inspectiom by Date Mantecaa823-7104' - <br /> I Final Inspection by / s : Date Q Tracy 835-6385 <br /> Applicant'- Return all copies'to:-'"'Environmental-Health Permit/Services 1601 E. Hazelton-Ave P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> SEH 13-24 REV. 10/82 -( -3,T�. 10/82 500 <br />#g 14-26 • � � - <br />