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a <br /> i <br /> APPLICATION FOR PERMIT <br /> i' <br /> t SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> it 1601 E. HAZELTON AVE., STCCKTON, CA ,73 <br /> N0. <br /> Telephone (209) 466-6781 PERMIT ` <br /> i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED `O ��y <br /> i, (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 RulVrl gulat'ons o .the an Joaq in:JCoTo-1 Health District. <br /> Job Addresbdivi ionOwner's NamAddress Phone <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ELL REPLACEMENT DESTRUCTION (� <br /> PUMP INSTALLA ION SYSTEM REPAIR El OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r <br /> INTENDED USE - en BottomTYPE WELL PROBLEM AREA i• CONSTRUCTION SPECIFICATION'S X11 <br /> I Industrial [Manteca 4 iWell ExcavationI <br /> U Domestic/Private ❑ Gravel Pack Tracy Dia. of. Well Casing <br /> ❑ Pe is �Other Delta . <br /> rr� ation �- --� ;r---- Type of Casing r <br /> Y g �. Approx. Eastern Geophysical S ecifications it <br /> 71 Cathodic Protection i Depth p r� <br /> 1-1 <br /> Depth of Grout Seal +� <br /> F1 Other I Type of Grout Q <br /> a , Surface Seal Installed <br /> Repair _rk Done Type of;aPuIp, Q04 P. by <br /> State Work Done <br /> Well Destruction ❑ Well`Diameter Sealing Material (top 501) <br /> ---Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: esidence _ Commercial Other available within 2D0 feet.) i <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 s <br /> LEACHING LINE U Na". & Length of lines '1 Total length/size r <br /> FILTER BED Distance to nearest: Well Foundation Property Lire f <br /> SEEPAGE PITS f-1 Depth Size Number <br /> SUMPS L Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ; v <br /> i� <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 agents signature certifies the following: "I certify that'in the performance of the,work for`,whieh'tthis <br /> permit is issued, I shal emplo any person in such manner as to become subject to workman§ compensation laws of California.". r <br /> Contractor 's hiring or ub-c tr g si nature certifies the foliowingi "I certify that in the performance of.the work for which 1, <br /> this permit is issu sh 1 e la per subject to workman's c mpensation laws of'California.'• ,e ` <br /> r <br /> The applic u t r 1 q e sp e tions. Complete dr <br /> Signed X TitPe: gyse `�i� Date �L/ N <br /> I R DEPARTMENT USE ONLY <br /> Application Accepted by - Area Stk 466-6781 <br /> Additional Comments: _ '" , {] Lodi 369-3621 <br /> ;:- Pit or Grout Inspectiohn by 3 r 'k 1 `� t' ` 1l Date U Manteca 823-7104 <br /> Final Inspection b "� ; Date L ^� <br /> p y � Tracy 835; 6385 <br /> Applicant - Return all Copies to: irpnmental Hea th Perm't ervices 160 E, lton Ave., P.0.. ox_2009,-Stk., CAT 95201 '' f <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. + <br /> [NFO ..,., <br /> f " v <br /> 7-y , <br /> EH 13-24 REV. 10/82 _ 10/8 500 <br /> e <br /> 14-26 `""" -- A <br />