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APPLICATION FOR PERMIT g <br /> SAN JOAQUiN LOCAL HEALTH DISTRIC <br /> 1601 E. HAZELTON AVE., STOCKTON, (A ` PERMIT NO. �( <br /> Telephone (209) 466-6781 * ' �v'. .r <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED n , ', <br /> (Complete in Triplicate) t"" -wi <br /> Application is hereby made to the San Joaquin Local Health District for a permit t6uct 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 an Joaquinocal Health District. <br /> Job Address Al S-3 �hA.Subdivision Name <br /> Owner's Name dress Phone <br /> Contractor's Named/ L -cense No. 3 Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL 7 WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR LJ? OTHER U CJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 0 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V3 <br /> (J industrial U Open Bottom F]Manteca Dia. of Well Excavation w(� <br /> l�Domestic/Private F-1GravelPack F-1TracyDia. of Well Casing v ' <br /> Public C1 Other 0 Delta Type of Casing <br /> Fl Irrigation Approx. E] Eastern Specifications <br /> ❑Chodic Protection Depth <br /> atroecDepth of Grout Seal <br /> 17 Geophysical Type of Grout <br /> Other Surface Seal Installed by <br /> Repair Work Done U7 Type of Pump H.P. State Work Done A-'e-d_�P�� - <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/,ADDITION E) (No septic tank or seepage pit permitted 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 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 employ persons subject to workman's compensation laws of California." <br /> The applican ust 0 11 for-al required inspections. Completdrawing on reverse side. ' ` /l <br /> Signed X Title: �� Date: L-�L <br /> OR DEPARTMENT USE ONLY Stk 466-6781 <br /> Application Accepted by — Area <br /> Additional Comments: V Lodi 369-3621 <br /> Pit or Grout Inspection by Date LL] Manteca 823-7104 <br /> Final Inspection by ��� C�GN . — Date L7 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 16M E. Wazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO 4 <br /> J J <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />