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APPLICATION FOR PERMIT _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> PERMIT NO. - Ll <br /> Telephone (209) 466-6781 DATE ISSUED 5 <br /> PERMIT EXPIRES 1,YEAR FROM DATE ISSUED <br /> i (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 /> h described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No, 1862 for well/pump <br /> k and the Rules and Regulations off the.San 3oaouin Local Health District, <br /> Job Address ��✓y� �sl _ �it ! - _ Subdivision Name <br /> Address u� �(o ! Phone / f1 <br /> owner's Name Phone q!9gBg/J <br /> Contractor's me License No. <br /> TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT DESTRUCTION <br /> EJ <br /> PUMP INSTALLATION ] SYSTEM REPAIR OTHER LJ 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA r. CONSTRUCTION SPECIFICATIONS <br /> 17 Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation <br /> Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> LJ Public [j Other [] Delta Type of Casing <br /> I iIrrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical Type of Grout <br /> {�J Other Surface Seal Installed by <br /> Repair Work Done Type of Pump H•P• State Work Done +dA rz �L - fry <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/,ADDITION U (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: <br /> Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet:: <br /> Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> € Capacity Method of Disposal <br /> PKG. TREATMENT PLT. � TYPE/Mfg <br /> SEWAGE SYSTEM � Distance to nearest: Well. <br /> r Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE <br /> No. 9 <br /> I& Length of lines Total length/size <br /> [� <br /> 4 FILTER BED <br /> Distance to nearest: Well Foundation Property Line <br /> ! SEEPAGE PITS ❑ Depth Size Number <br /> Ili <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> 1 L� <br /> DISPOSAL PONDS <br /> 1 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 /> t 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 following: "I certify that in the performance of the workforwhich <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applic t must all far all required inspections. Complete draw.Uw on reverse side. <br /> Signed X Title: <br /> Date: f <br /> ARTMENT USE ONLY - �tk 466-6781 <br /> App kation Accepted by T Area [? r <br /> s 11 Lodi 369-3621 <br /> Additional Comments: Manteca 823-7104 <br /> Pit or Grout Inspection by Date <br /> Final Inspection by <br /> _ Date .Y 19 Zu L 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 /> DATE PERMIT NO. <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY - G� �7 q <br /> I NFO C.-�. S U3 <br /> 10/82 500 <br /> EH 13-24 REV, 10/82 <br /> 14-26 <br />