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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT +q 2 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. J <br /> Telephone (209) 466-6781' , <br /> DATE ISSUED!J �J <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i <br /> (Complete in Triplicate) J <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/o`Ynstalllthe 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 Regulatio is o the San Joaquin Local Health District. <br /> Job Address / AL Subdivision Name <br /> Owner's Name Address ,�7��� Phone <br /> Contractor's Name tiA� ,� (�� License,No. Phone <br /> Od � <br /> TYPE OF WELL/PUMP WORK: - NEW WELL ❑ WELL REPLACEMENT. DESTRUCTION % (71) <br /> PUMP INSTALLATION SYSTEM REPAIR ' OTHER U 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE ^S� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom []Manteca Dia, of Well Excavation (' <br /> Domestic/Private ❑Gravel Pack D Tracy �.,. Dia. of''Well Casing <br /> ❑ Public F-1 Other Delta Type of Casing <br /> V Irrigation Approx. Eastern Specifications <br /> Catoic Protection Depth <br /> ❑ hdPttDepth of Grout Seal I <br /> Geophysical Type of Grout <br /> Lf Other Surface Seal Installed,by t <br /> i <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top.50') <br /> Depth Filler Material (Below 50') &: r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION [J (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 fe t: ne Water table depth <br /> SEPTIC TANK Type/Mfg — pacity No. Compartments <br /> PKG, TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM 11—�� Distance to nearest: Well` Foundation Property Line <br /> DESTRUCTION L_.1 W <br /> LEACHING LINE No. & Length of lines s— `7® Total length/size <br /> FILTER BED Distance to nearest: We11fZ21E�Foundation Property Line /gJVX0 <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS A Distance to nearest: WelI Foundation —T—eX Property Line- . /40-�,P7' r <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the,work will be done in °accordance wjth 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 /> Perm it is iss d, I shall not employ any rson in such manner as to become subject to'workmans compensation laws of California." <br /> Contractor's ring or sub-contracting ature certifies the following: "I certify that in the performance of the work for which <br /> this perm' i ed, I shall employ sons subject to workman's compensation laws of California." <br /> The appl t m -1 f all re ed ins ctions. Compl to dr g on reverse:'side. <br /> Signed Title: Date: <br /> DEPARTKW USE ONLY <br /> Application Accepted by Area <br /> ' Stk 466-6781 <br /> Lodi 369-3621 <br /> Additional Comments: <br /> Manteca 823-7104 <br /> Pit or Grout Inspection by Date c� L� <br /> Final Inspection by �'.,.,�—�� Date Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 16011E./Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY j..DATE <br /> PERMIT NO..INFO p � p3 5 <br /> 0 <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> r <br /> 14-26 <br />