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APPLICATION FOR PERMIT <br /> uuu SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FEB < . <br /> B 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. l <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> SAN JOAQUIN LOCAL $� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> HEWM D1M ,4?t (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora 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 Dis rict. /! <br /> Job Address - �'h- r3(ne (L� <br /> Owner's Name Address Phone 2_3 <br /> Ap fe t 04 <br /> Contractor's Name 44 Phone T:)7 <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT F_� DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <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 /> I_J Industrial U Open Bottom F-I Manteca Dia. of Well Excavation <br /> LJ Domestic/Private F_j Gravel Pack ❑Tracy Dia. of Well Casing <br /> 17 Public f-1 Other Delta Type of Casing <br /> °'Irrigation Approx. Eastern <br /> Depth Specifications <br /> ❑ Cathodic Protection Depth of Grout Seal U(� <br /> 17 Geophysical Type of Grout kn <br /> LJ Other Surface Seal Installed by <br /> Repair Work Done [J Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') IF _ <br /> Depth Filler Material (Below 50') LA <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION F1 REPAIR/ADDITION EJ (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 Cl <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 U 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 applicant must c or all required inspections. Complete dr ng og reverse side. <br /> Signed X hj op�-�- Title: �s��.� Date: <br /> ,O FOR DEPART E USE ONLY D G Stk 466-6781 <br /> Application Accepted by li✓�`/ Area <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date - e Manteca 823-7104 <br /> Final Inspection by Date _2_ L7 Tracy 835-6385 <br /> Applicant - Return all copi s Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />