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APPLICATION FOR PERMIT <br /> �I n� SAN JOAQLiN LOCAL HEALTH DISTRICT 2 <br /> 1� 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. � <br /> Telephone (209) 466-6781 DATE ISSUED 3 if 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 Regulations of t e San Joaquin Local Health District. <br /> � /1/ <br /> Job Address O i Subdivision Name �l <br /> Owner's Name k Address =/ �(/ rJ��adu< Phone <br /> c� <br /> Contractor's Name License No. �c -�aE % Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION I <br /> PUMP INSTALLATION (�' SYSTEM REPAIR ❑ OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK !d'Q SEWER LINES ZOO DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F-1 Industrial U Open Bottom E Manteca Dia, of Well Excavation %a 1r <br /> FS?Domes tic/Private Gravel Pack Tracy Dia. of Well Casing , <br /> r❑ Public C1 Other Delta Type of Casing <br /> V Irrigation Approx. E] Eastern <br /> Specifications <br /> ❑ Cathodic Protection Depth Depth of Grout Seal <br /> ❑Geophysical T <br /> _ Type of Grout 1f _ <br /> Other <br /> �--� Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump -S,,j, H.P. State Work Done <br /> Well Destruction Well Diameter s` Sealing Material (top 50') /4A_­,I - ' .a <br /> �ng+, _�_ ._ <br /> Depth /.24^ Filler Material (Below 50') ct�s � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION r_1REPAIR/ADDITION i J (No septic tank or seepage pig perm5l ed if public--sewer-is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <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 ❑ 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 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS Ci Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C� <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 t 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 employ persons subject to workman's compensation laws of California." <br /> The applicant m call for al requ' ed inspections. Complete drawinn re ., a side. <br /> Signed X ' �� �t Title: _ _� Date: <br /> ARTM 'USE ONLY <br /> ApplicatioiYAccepted y Area - 3- Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection bye��Health <br /> (_ Date 7— S�- Manteca 823-7104 <br /> Final Inspection by/�i( / Date )t$ Tracy 835-6385 <br /> Applicant - Return all copies to: Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY �7 DATE <br /> r� PERMIT N0. <br /> INFO � p_� <br /> EH 13-24 REV. 10/820 G%� 10/82 500 <br />