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APPLICATION FOR,PER;1T <br /> SAN ,OAQU2! LOCAL. HE".LTH 'OiSTRICT 3�1p0� <br /> 1601 E. HAZELTON AVE STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466--67811 # <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p <br /> R (Complete.in Triplicate) <br /> .. °' Application is hereby made to the San 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 ,loaqu focal Health District,: <br /> Jab Address f�+'1/ Subdivision Name <br /> Owner's Name Address ] Phoneme ()" <br /> Contractor's Name License No. / Phone <br /> 6 <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION G <br /> PUMP INSTALLATIONSYSTEM REPAIR OTHER U <br /> D15TANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1� Industrial U Open Bottom F7 Manteca Dia. of Well Excavation <br /> LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Public [-j Other Delta " Type of Casing <br /> V Irrigation Approx. Eastern Specifications <br /> Cathodic Protection p <br /> F-1CathodicDepth of Grout Seal <br /> Geophysical Type of Grout ' <br /> LJ OtherSurface Seal Installed by t <br /> Repair Work none Type of Pump H.P. y 1 State Work Done <br /> Well Destruction IJ Well Diameter Sealing Material (top 501) <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 /> f available within 200 feet.) <br /> Installation will serve: Residence —Commercial Other <br /> Number of living units: L_. Number of bedrooms Z Lot size B.« <br /> Character of soil to a depth of 3 f^eet: Water table depth d <br /> SEPTIC TANK , Type/Mfg C Capacity 1.)LS4) No. Compartments <br /> PKG. TREATMENT PLT.' .❑ Type/Mfg ?,� #( Capacity Method of Disposal <br /> SEWAGE SYSTEM ` Distance to nearest:, Well 075" Foundation Property Line <br /> 4 <br />' pE$TRUCTION ❑ •" � " r <br />` LEACHING LINE No. & Length'of lines 3 O z Total length/size <br /> i Foundation Property Line / S <br /> F" FILTER BED Distance to nearest: Well . �d- <br /> f SEEPAGE PITS Depth ' 4 Size a Number <br /> E SUMPS �� Distance to nearest: Well Foundation x Property Line <br /> DISPOSAL PONDS ❑ , - {^ r fj <br /> 3 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, 3 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 shal em Ioy persons,'subject to workman's"compensation laws of California." <br /> The appli t m t,ca for equired inspections. Complete drawing on reverse side. <br /> Date: 0_40 <br /> �j <br /> Signed s M-� Title: /L�✓ <br /> FOR DEPARTMENT USE ONLY Stk 466-6781 <br /> pplication Accepted <br /> by <br /> Area <br /> Lodi 369-3621 <br /> Additional Comments: ``" <br /> Date Manteca 823-7104 <br /> Pit or Grout Inspection CJS-� 835-6385 <br /> Final Inspection by <br /> Date L Tracy <br />{ Applicant - Return all copies to: Envr nmental Health Permit/Services 16 1 E. zelton Ave., P.O. Box 2009, St k., GA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED, RECEIVED BY HATE Q PERM/IT`�NO. <br /> INFO LOCJ �Q <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />