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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 1(p�— <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 and Regulations of.the San Joaquin Local Health District.. <br /> Job Address X41PID9 Subdivision Nares <br /> Owner's Name Address �/�� <br /> Contractor's -:1. icense No. /Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC_TANK SEWER LINES- DISPOSAL FLD_. PROP. LINE <br /> MFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open`Bottom Manteca Dia. of Well Excavation <br /> U Domestic/Private Q Gravel Pack 0 Tracy-. Dia. of Well Casing <br /> 17 Public F7I other Delta <br /> - -.Type of Casing <br /> 71 irrigation Approx. Eastern <br /> Cathodic Protection <br /> Depth Specifications <br /> Depth of Grout Seal r <br /> Geophysical <br /> [ <br /> Other <br /> Type of Grout i J t�, <br /> Surface Seal;installed by � <br /> Repair Work Done D Type of Pump H.P. State Work Done ) <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ r <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [J (No .septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) f <br /> Installation will serve: Residence Commercial Oth7er . <br /> Number of living units: __/_-__ Number of b drooms Lot size 3 . <br /> Character of soil to a depth of 3 feet: _ - r Water table depth IAO,� <br /> I <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments, <br /> i <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal .Y;1 <br /> SEWAGE SYSTEM II—�--�� Distance to nearest: Well Foundation Property Line ; <br /> DESTRUCTION �J <br /> LEACHING LINE U No. & Length of lines Total length/size ` <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Z r.- Size _ � � Number <br /> SUMPS �� Distance to nearestW'ell np Foundation 1 p �,f— Property Line <br /> DISPOSAL PONDS <br /> 1 hereby certify that ,kyfiave 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 IE <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmans 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 /> N <br /> The applicant must all for all re ed inspections. Complete drawing on reverse side. <br /> Signed X -0— Title: Dater <br /> F DEPARTM. T US ONLY /'� n <br /> Application Accepted by Area (/ � � Stk 466-6761 <br /> Additional Comments: Lodi 369-3621 <br /> it or Grout Inspection by Date Manteca 823-1104 r. <br /> Final Inspection by Date Tracy 835-6385 " <br /> Applicant - Return all copies to: Environmental H lth Permit/Services 1601 E. Haze ton/Ave. O. Box 2009, St k., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE �PERMITINFO41 <br /> EH 13-24 REV. 10/82 10/B2 500 ' <br /> 14-26 <br />