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r <br />" APPLICATION FOR PERMIT <br /> SAN JOAQU:N LOCAL.HEALTH DISTRICT �} <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. J f 14 U <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 theRules qd Regulations of the <br /> Job Address San Joaquin Local Health District. <br /> ss .IL1Jth Subdivision Name <br /> Owner's Name e Address Phone <br /> C❑ntractor's Name t Lt.E L <br /> icense No. Phone a7. IeS <br /> y ` TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ /''i OTHER U <br /> DISTANCE.TQ_NEAREST.:_SEPTIC TANK - _ ..._ SEWER L,1NES.• ..: _ -t ,,DISPOSAL FLD, _.._._ _ PROP. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑Gravel Pack ❑ Tracyti*rw•,«.`..�—.^_ Dia. of Well Casing _ <br /> ❑ Public = ❑I Other ❑ Delta } Type of Casing <br /> Irrigation Approx ❑Eastern Specifications <br /> Cathodic Protection <br /> ❑ Dep <br /> Depth of Grout Seal <br /> Geophysical i <br /> ❑ p TyFpe of Grout - <br /> ❑Other Surface SealyInstalled by <br /> Repair Work-Done �❑ Type of Pump H.P. r State Work'Done <br /> A Well Destruction ❑ WelIj Diameter ___ SealinglMaterial3(top'50') <br /> Depth Filler Material (Below 50') r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ +REPAIR/,ADDITIONS{No septic tank or seepage pit permitted if public sewer is r <br /> available within 200 feet.) <br /> Installation will serve: R sidence _ Commercial Other <br /> Number of living units Number ofs bedrooms a o 'Lot size s DLO 0 <br /> Character of soil to a depth of 3 feet: �) 1 � _ Water table depth <br /> SEPTIC TANK ❑ i Type/Mfg s Capacity'% No. Compartments ((�1 <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity i Method ❑ Disposal <br /> SEWAGE SYSTEM ° �_Distance_to•.nearest-."Wel-1. Foundation.­"" Property Line <br /> DESTRUCTION ❑ i ( ' <br /> LEACHING LINE No. & Length of lines '— Notal' length/size <br /> FILTER BED Distance to nearest: Well Foundation {, Property Line <br /> SEEPAGE PITS Depth �+ Size <br /> Number <br /> SUMPS 'Distance to nearest: Well Foundation . :, Property Line <br /> 4 DISPOSAL 'PONDS ❑ ! <br /> I hereby certify that I have prepared this application;andFthat 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-fol.l.owing.: "I,acer.t:ify that in the performance of the work for which this <br /> permit is issued, I shall not employ ary,person in such manner as to become subject to workmant compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the followin.g:_ "I certify that in the performance of the work for which <br /> t` ermit is ,issue I sh 11 employ persons subject to workman"s compensation laws of California." <br /> The applic ust 11 for a 1 r uir inspections. Complete drying on <br /> I Si Title: (i. Li Date: j <br /> �(3 DE ARTME SE ONLY ,�,� Stk 466-6781 <br /> ! Application Accepted Area _--- — ❑ <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection U Date �� ❑ Manteca 823-7104 <br /> Final Inspection b Date0=� ❑ Tracy 835-6385 <br /> Applicant - Return all c to: V�nmlHealth Permit/Services 1601 L. Hazelton Ave., P,O. Box 2009, St k., CR 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> k. EH 13-24 REU, 10/82 10/82 500 <br /> 14-26 <br /> 1, _ <br />