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1 <br /> }S0 ,p <br /> APPLICATION FOR PE=.!'iiT <br /> i <br /> SAN .IOAQLiFi LOCA!,'tip= .LTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781•- DATE ISSUED <br /> I� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to theip5an Joaquin Local Health District fora 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 L cal HSOth District. <br /> Job Address Subdivision Name <br /> Owner's Name Address Phone <br /> Contractor's Name icense No. Phone <br /> TYPE Of WELL/PUMP-WORK: NEV! WELL WELL REPLACEMENT DESTRUCTION <br /> `aV <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U W i <br /> V <br /> DISTANCE TO NEAREST: SEPTIC TANK', SEWER LINES DISPOSAL FLD. PROP. LINE }t <br /> FOUNDATION 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 F-1 Gravel Pack [j Tracy Dia, of Well Casing <br /> Public Other Delta Type of Casing <br /> Ljlrrigation Approx. Eastern Specifications <br /> Cathodic ProtectionDepth <br /> Depth of Grout Seal <br /> Geophysical 1° Type of Grout <br /> Other �I Surface Seal Installed by <br /> Repair Work Done G Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50')Al — <br /> If <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> 46.�_7 available within 200 feet.) <br /> i, Installation will serve: Residence Commercial _ Other <br /> Number of living units: it Number of bedrooms Lot size <br /> '�" _-4i— Water table depth <br /> Character of soil to a depth a�f 3 feet: , <br /> SEPTIC TANK Type/Mfg Capacity / No. Compartments <br /> PKG. TREATMENT PLT. [] Type/Mfg Capacity Method of Disposal <br /> -SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <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,Aa Size13 Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ !I' <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, 1 shall not employ any person in such manner as to become subject to workmant 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, 1 shall employ persons subject to workman's compensation laws of California." <br /> The applica t fo �lrequir nspections. G mplete drawii on reverse ide <br /> Signed X Title: � � r/G Date: l�J <br /> !! 0 EPA ANT USE ONLY Area Q� Stk 466-6781 <br /> Application Accepted by' <br /> d <br />' Additional Comments: i! Lodi 369-3621 <br /> i Date �3 Manteca 823-7104 <br /> Pit or Grout Inspection byuU-`���� <br /> Final Inspection by 'R Date 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 /> =��— <br /> AMOUNT: DUE AMOUNT REMITTED RECEIVED BY DATES2pPERM/ITN0. <br /> L� b 3 �! <br /> 10/82 500 <br /> EH 13-24 REV. I0/82 <br /> 14-26 <br />