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1 T A APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> v, 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED `'E' � OJ <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 rl I ot 5 E. Alp f1 Subdivision Name n ' <br /> Owner's Name G^ Address r11121s5 E• La l Phone <br /> Contractor's NameNbkq License No 33331q " Phonecle <br /> W <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U 1 <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 <br /> Industrial U Open Bottom F� Manteca Dia. of Well Excavation <br /> U Domestic/Private 7 Gravel Pack ❑ Tracy Dia. of Well Casing <br /> F� Public F-1 Other 0 Delta Type of Casing <br /> [ j Irrigation Approx. [] Eastern Specifications <br /> ❑Chodic Protection Depth <br /> atroecDepth of Grout Seal <br /> ❑Geophysical Type of Grout <br /> Other Surface Seal Installed by J <br /> Repair Work Done [J Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') f <br /> Depth Filler Material (Below 50') v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION X (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence '9," Commercial _ Other <br /> Number of living units: Number of bedrooms 2 Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines d Total length/size 4c) <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth as, Size [� Number <br /> SUMPS 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 em/�i�rnspections. <br /> persons subject to workman's compensation laws of California." <br /> The applican m t call f 11 Complete drawing on �e-vverse side. <br /> Signed <br /> Title: Date: <br /> R DEP MENT USE ONLY ,i <br /> Application Accepted by t Area Stk 466-6781 <br /> Additional Comments: �� EJ Lodi 369-3621 <br /> Pit or Grout Inspection by Date 2/3 3 L� Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all c to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20D9, St k., CA 95201 <br /> FEE 93 <br /> BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />