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A £ <br /> APPLICATION FOR-PERMIT" <br /> SAN JOAQUIN.LOCAL'HE:ALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED ' <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 Joaqui County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of a San-Joaqui ocal UeAth s c <br /> Job Address 5 di Vision Name w <br /> Owner's Name `£ "' z ":' Addr s Phone <br /> Contractor's Name icense No. / Phone •. <br /> TYPE OF WELL/PUMP WORK: N l WELL V_.-SYSTEM <br /> ELL REPLACEMENT [� DESTRUCTIONPUMP INSTALLATION REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SER LINES s' DISPOSAL FLD. �� PROP. LINE W <br /> FOUNDATION AGRICULTURE W.EE_L-1' OTHER WELL PITS/SUMPS i } <br /> ^--i-=IAT•ENDED-USE —'QTYPE-OF-WEW PROBLEM AREA`S h'•"`O STRUCTIONJSPECIFICATIONS" <br /> I� Indu trialpen Bottom []Manteca Dia'. of Well Excavation /.: 'y <br /> mestic/Private Gravel Pack Tracy Y Dia:of'We`l Cas;ng AP t�'L <br /> Publ i Other Delta <br /> rigation Approx. Type� Eastern � '�'� <br /> Depth %,Specifications <br /> Cathodic Protection P Depth of-Grout'Seal, <br /> ❑Geophysical <br /> x ❑Other Type of Grout <br /> Surface Seal Install ed'by 1Repair Work Done ❑ Type of Pump Zll�x — H.P. 'r 1l -:5 State Work Done <br /> Well Destruction �T�WelI Diameter Sealing Material.,,(top 501) % i <br /> Depth Filler Material (Below 50') Zyel, x <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (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- . Ej Type/Mfg T .Capacity No. Compartments - <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line <br /> y. DESTRUCTION ❑ t <br /> LEACHING LINE No, & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation:e i Property Line <br /> :SEEPAGE PITS Depth Size — - Number <br /> -r' SUMPS LI Distance to nearest: Well Foundation Property Line <br /> i 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 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 workman s compensation laws of California." <br /> I <br /> Contractor's hiring or sub-contracting s' nature certifies the following;' "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ p Ons subject to workman's compensation laws of California." f . <br /> The applOitional <br /> c 11 for 11 req r insp talons. Complete drawin n re se side. <br /> i <br /> Signed % Title: �y,/_ i Date: ( Z <br /> R DEPARTME USE ONLYAAccepted byArea ❑ Stk 466-6781AComments: A. Lodi 369-3621 <br /> Pit or Grout Inspection b Date l l D anteca 823-7104 <br /> Final Inspection by Date y1{l Tracy 835-6385 <br /> Applicant -. Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 : <br /> E <br /> FEE- -BASE— AMOUNT -DUE -AMOUNT REMITTED, RECEIVED BY - DATE - —PERMIT NO. - - <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> I4-26 <br />