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'..��" /Ota• � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1`601 E. HALELTON AVE., STOCKTON, CA PERMIT N0. �� 7�1 <br /> Telephone (209) 466-6781 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 the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address 1 `7 Subdivision Name �/ <br /> Nam, /�l/r(L Address <br /> Owner's Naml ® /int Phone ; <br /> License No. Phone <br /> Contractor's Name <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR V OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial [f Open Bottom D Manteca Dia. of Well Excavation <br /> U Domestic/Private F_�Gravel Pack ❑ Tracy Dia. of Well Casing r_ <br /> Public [_�Other [ Delta Type of Casing lQ tiU�+v, <br /> V Irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical Type of Grout lu�,i11 <br /> LJ Other Surface Seal Installed by <br /> Repair Work Done [J Type of Pump H.P. State Work Dore <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L) REPAIR/,ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: .Reesidence x Commercial _ Other <br /> Number of living units: J Numbe, of bedrao s Lot size , i <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg <br /> Capacity Method of Disposal <br /> SEWAGE SYSTEM � Distance to nearest: Well <br /> Foundation Property Line <br /> DESTRUCTION z � f <br /> No. & Length of lines C/L/ Total length/size 'L � r <br /> LEACHING LINE g <br /> FILTER BED Distance to nearest: Well <br /> Foundation __"�� Property Line . ___. ��j <br /> SEEPAGE PITS Depth � Size n? .2�2$ Number <br /> SUMPS Distance to nearest: Well <br /> 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 fol owina: "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 t 11 for all req it inspe ions. Complete dr�y�ng on rse sid pate: <br /> Signed X Title: C/i_/ <br /> FOR P NT U ONLY 5tk 466-6781 <br /> Application Accepted by Area <br /> Lodi 369-3621 <br /> � <br /> Additional Comments: —,�[� Manteca 823-7104 <br /> to, Yatlor Grout Inspection Date ��— S `�� <br /> { al Inspection by Date �? icy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 <br /> [FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BYDATE PERMIT NO. <br /> C7� <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />