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A `` APPLICATION FOR PERMIT <br /> p <br /> SAN JOAQUIN LOCAL HEALTH DISTRfCT ] <br />' 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, <br /> Telephone (209) 466-6781 2 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; <br /> 3 (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 the San Joaquin Local Health District. <br /> Job Address Subdivision Name <br /> Owner's Name ="d dress Phone <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT 0. DESTRUCTION pp <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER lltJ <br /> i" DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES 4� DISPOSAL FLD. PROP. LINE - 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1 Industrial �� <br /> ❑Open Bottom [�Manteca Dia. of Well Excavation <br /> 7— 9Domestic/Private Gravel PackIX <br /> 7racy Dia. of Well Casing <br /> 1-1 Public F-1 Other Delta <br /> L( IrrigationApprox. Eastern Type of Casing _` <br /> Cathodic Protection Depth iSpecificationsAf As <br /> - <br /> ' Depth ofGrout al <br /> F Geophysical <br /> -. Type;of Grout �� <br /> LJ Other 'j, q <br /> . ,Surface Seal Installed.-by <br /> Repair Work DoneEJ- Type of Pump"' <br /> H.P. fre <br /> State Work Don p r <br /> €,Well Destruction U Well Diameter _j Sealing Material (top 50') <br /> ` Depth Filler Material (Below 50') <br /> .k " TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> } , available within 200 feet.) <br /> Installation will serve: Residence Commercial Other + x <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 %'w Capacity o. Compartments i3n <br /> PKG. TREATMENT PLT. Type/Mfg Capacity, Method of Disposal - V� <br /> .Septic Tank Distance:to nearest: Well Foundation Property Line pe <br /> f Destraction <br /> ❑ <br /> ` LEACHING LINE LVNo. &'Len th of lines 6 j <br /> 9 Total length/size ` <br /> FILTER BED . 1 Distance to nearest: Well "-f- Foundation Property,Line „ <br /> SEEPAGE PITS Cj Depth F- s Size Number <br /> SUMPS U y Distance to nearest: Well Foundation Property'Line t, <br /> DISP05AL PONDS I f7 J <br /> r. <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 appl'ga t must caTli�f r al r quired inspections. Complete drawing on reverse side. <br /> Signed x - 3 <br /> Title: ; Date: <br /> ? DEP NT`USE ONLY ❑ <br /> Ap ication Accepted by Area Stk 466-6781 <br /> Additional Comments:- <br /> 0 Lodi 369-3621• <br /> Pit or Grout Inspection by Date -/@ �, Manteca 823-7104 <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 4 - <br /> FEE BASE AMOUNT DUE '--C'AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV.-10/8 4 " 10/82 300 <br /> 14-26 <br />