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APPLICATION FOR PERMIT <br /> SAN JOAQbiN LOCAL HEALTH DISTRICT C� <br /> 1601 E. HAZELTON .AVE., STOCKTON, CA PERMIT NO, <br /> Telephone (209) 465-6781 <br /> AlPERMIT EXPIRES I YEAR FROM GATE ISSUED DATE ISSUED `"C <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 Regulations of the San Joaquin Local Health District, <br /> Job Address v 0 I'5 CO Kr. Subdivision Name <br /> Owner's Name Mjk�" Mes q D U 11 AddressComy <br /> _! li(11�C_C9 N,�(�(iG Phone <br /> Contractor's Namewm License No. (D Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL J WELL REPLACEMENT DESTRUCTION J <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR J OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y <br /> J Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation <br /> J Domestic/Private ❑ Gravel Pack { Tracy Dia. of Well Casing <br /> L7 Public Other F_� Delta <br /> Type of Casing <br /> J Irrigation Approx. F-] Eastern <br /> Specifications <br /> [ Cathodic ProtectiDepth <br /> p Depth of Grout Seal f <br /> Geophysical Type of Grout - <br /> jJ Other <br /> Surface Seal Installed by <br /> Repair Work Done [j Type of Pump H.P. State Work Done <br /> Well Destruction J Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> C> <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Lj REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence _ Commercial Other available within 200 feet.) <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK U 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 �5L <br /> LEACHING LINE jJ No. & Length of lines Total length/size <br /> FILTER BEI) ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS D Depth . Size Number <br /> l: <br /> SUMPS Lj Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS J <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-contr cting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is iss d, I hall ploy persons subject to workman's compensation laws of California." <br /> The appl nt u al or requi inspections. Complete drawing on reverse side. f <br /> Signed K Title: /71.8 Dater S =�?Z <br /> FOR DEPARTM <br /> Application Accepted by _WoArea /j— Stk 466-6781 <br /> Additional Comment ] Lodi 369-3621 <br /> Pit or Grout Inspection by Date U Manteca 823-7104 <br /> Final Inspection by Date L Tracy 835-6385 <br /> Applicant - Return all i to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. J <br /> INFO <br /> EH 13-24 REV. 10/82 r > 1 10!82 500 j <br /> 14-26 <br /> no <br />