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APPLICATION FOR PERIMI T , <br /> ;i <br /> SAN JOAQUiLN LOCAL HFALTI', DiSTRICT <br /> -1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, <br /> Telephone (209) 466-6781. <br /> DATE ISSUED K3 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> a <br /> (Complete inTriplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to'construct and/or instaII 'the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage A No. 1862 for w • /pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> i <br /> Jab Address - Subdivision Name 49' �+�� �� CQ <br /> Owner's Name ` Address Phone t <br /> Contractor's Name �' No. �' Phone J <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑} <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U <br /> f � <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE <br /> j <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYRE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />• Industrial ❑ Open Bottom [] Manteca Dia. of Well Excavation <br /> .r <br /> Domestic/Private Gravel Pack ❑Tracy Dia. of Well CasingX. <br /> - <br /> ❑ Public ❑ Other ❑ Delta ( Type of Casing <br /> ❑ Irrigation Approx. ❑ Eastern Specifications e.IFL f <br /> Cathodic Depth Protection <br /> F-1 Depth of Grout Seal <br /> ❑Geophysical Type of Grout <br /> ❑Other Surface Seal Installed b <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction Well Diameter Sealing Material (top 501 <br /> iDepth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONj f (No septic tank or seepage pit permitted if public sewer is l I <br /> available within 200 feet.) <br /> Installation will serve: Residence , Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size � <br /> Character of sail to a depth,of 3 feet: ' Water table depth i <br /> SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments 1 <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION E <br /> LEACHING LINE No. & Length of lines -Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Properly Line <br />' f <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑l Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 workman5 compensation laws of California." <br /> C 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 /> The applicant must all fo all re red tions. Complete drawing on reverse side. <br /> Signed X Title: i1 ,a'g Date: <br /> R DEPARTMENT USE ONLY �� ❑ Stk 466-6781 <br /> Application A pted by �� Area <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by <br /> Date �b-8 3 ❑ Manteca 823-7104 ; <br /> Final Ipection by Q D a t e —0-9 3 - L7 Tracy 835-6385 <br /> ns <br /> Applicant - Return all copies to: Environ a al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i <br /> =BASE AMOUNT ,DUE AMOUNT REMITTED RECEIVED BY DATE ryy �-? <br /> [ 1,� (g a b -Ur-k) <br /> 'T # <br /> [� 10/82 500 <br /> EH 13-24 REV. 10/82 �t �L r TILL G i <br /> 14-26 <br />