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3� <br /> ' APPLICATipN FOR PERMIT <br /> k SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON,.CA PERMIT NO. Ji <br /> Telephone (209) 466-6781PERMIT EXPIRES'l YEAR FROM DATE ISSUED DATEISSUED / <br /> (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 d Regulations the San JoaJgpin Local Health District. { <br /> Jab Address �' 4� /'f Subdivision Name r <br /> Owner's Name Address S Phone' <br /> Contractor's Name " License No. Phone <br /> I - <br /> TYPE OF WELL/PUMA WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE To NEAREST: SEPTIC TANK A9 0 SEWER LINES ' <br /> 'f N!lyv� � <br /> FOUNDATION 1 <br /> fi AGRICULTURE WELL _�� OTHER WELL/&'�_Zt=SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /\f" <br /> Industrial Open Bottom [�Manteca Dia, of Well Excavation / l�f9G Q� l r <br /> �mestic/Private Qhr j� 4 <br /> Gravel Pack Tracy Dia, of WelI Casin y <br /> Pub is Ej Other E]Delta 9 r <br /> L_1 Irrigation Type of Casing of <br /> Irrigation f,/[ <br /> '�'>; Approx. �] Eastern _ <br /> I" Depth Specifications <br /> [�Cathodic Protect,gn P <br /> �Geaphysicai Depth of Grout Seal ��,pb <br /> 17 Other ',Y Type,of Grout. <br /> Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump ' H.P. State Work Done ,. <br /> Well Destruction Wel meter; Sealing Material (top 50') <br /> 4.!►r+lJ <br /> Dep Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INsfif A REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> [[[ <br /> 'Installation will serve: Residence _ Commercial Other available within 200 feet.) <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 a <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION 0 <br /> LEACHING LINE [JNo. & Length of lines Total length/size <br /> FILTER BED E] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Cj Depth Size . Number <br /> SUMPS 0- Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ED <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<Lgcal 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 workmant,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 appli ant m cal 11 required inspections, Complete draw. on reverse ide. <br /> Signed X Title: �fiL <br /> Date: 4 <br /> i <br /> F DEPARTMENT SE Q Y <br /> Application Acc ted by W t-0 Area D 2 f�IC Stk 466-6781 ! <br /> Additional Comments: <br /> Lodi 369-3621 <br /> Pit or'rGrout Inspection #by " Date / Manteca 823-7104 } <br /> Final inspection by bate Tracy 835••6385 j <br /> Applicant - Return all copies tonm n61—Health Permit/Servigs 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE SASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 <br /> 14-26 10/82 500 <br /> .. i <br />