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APPLICATION FOR PERMIT <br /> SP.N UOAQUiN LOCAL HEALTH DISTRICT 13 <br /> 1601 E. HAZELTON AVE,, STOCKTON, CA PERMIT NO. Cl <br /> Telephone (209) 466-6781 r� <br /> DATE ISSUED —,3 <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 Regulation of the San Joaquin Local Health District. <br /> Sob Address Subdiviissiion Name - �r *. <br /> Address / 6 � Phone �p ,�q <br /> Owner's Name 3 <br /> Contractor's Name License No., Phone r <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ 1 <br /> FDISPOSAL FED. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> AGRICULTURE WELL/ OTHER WELL PITS/SUMPS <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREAf �CONSTRUCTI�JN SPECIFICATIONS <br /> 0 <br /> J Dia. of Well Excavation <br /> Industrial. U Open Bottom Manteca f' FI <br /> Domestic/Private Gravel Pack Tracy iF 4 Dia. of We11.Casing <br /> I_ t <br /> Public �j Other [] Delta J Type of Casing <br /> Irrigation Approx. ] Eastern �, x Specifications- <br /> El <br /> ` <br /> Cathodic Protection Depth f <br /> � q.� Depth of GroutvSeal s..' <br /> IF[F Geophysical Type of Grout_,,. .__ <br /> U Other / Surface Seal Installed by <br /> 4 / n 4 — <br /> Repair Work Done 1 Type of Pump H•P.-J,==" StateTWorKvDoneT <br /> Well Destruction ❑ Well DiameterSealing Material (top 50'J, Filler Material (Below Depth <br /> l50') -r <br /> ± TYPE OF SEPTIC WORK: NEW INSTALLATION LI EPAIR/ADDITION U',(N6;septic. tank or seepage pit permitted if public sewer is 01 <br /> available within 200 feet.) <br /> Installation will serve: Residence r ./ Commercial f Other. <br /> !—. <br /> Number of living units: Number of bedrooms Lot size �) <br /> it_ i` _• l Water table depth <br /> ..,�.--_ __Character 6f sail1to,a.d_epth,ot,3rfeet: <br /> ' No. Compartments <br /> SEPTIC TANK Type/Mfg Capacity r _ <br /> PKG-. TREATMENT PLT. ❑ Type/Mfg Capacity w Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest. Well Foundation Property Line <br /> DESTRUCTION ❑ 1 <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 f Size Number <br /> SUMPS U 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 workman_ 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 mploy persons subject to workman's compensation laws of California." <br /> The applica ust all required ins ction`s. qC?mplete dra on re erse side. <br /> Signed X <br /> le: pater 4 <br /> FOR DEPARTMENT USE ONLY � <br /> l Area Stk. 466-6781 <br /> Application Accepted by <br /> Lodi 369-3621 <br /> 'u Additional Comments: <br /> Pit or Grout Inspecti4byDate Manteca 823-7104 <br /> Final Inspection by <br /> ate rTracy 835-6385 <br /> Applicant - Return all copienvironme tal H alth Permit/Services 1601 Ha"tooe., P.O. Box 2009, Stk., CA 95201 <br /> rFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE <br /> �Q PERMIT NO. <br /> INFO :; T3—(W <br /> l 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />