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APPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f ^� <br /> f 1601 E. HAZELTON AVE., STOCKTON., CA PERMIT N0. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE'ISSUED 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 Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local H h District• <br /> Job Address <br /> division Name p <br /> Owner's Name Ad ss Phone <br /> Contractor's Name P License No. Phone,r�( '-§'6_ <br /> TYPE OF WELL/PUMP WORK: EW WELL WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP,INSTALLATION [] SYSTEM�.RFPPA•µIR ❑ OTHER ❑ f T <br /> DISTANCE-TO.NEARESTi'SEPTIC TANK" _ SEWER LINE'S �" .Y DISPOSAL-FLD.)� '-. PROP:-LINE -- �-•-- <br /> FOUNDATION AGRICULTURE WELL 'OTHER 4IELL PITS/SUMPS 1 <br /> INtlNOED_US_E���� �TY.PE_OFWELL� _,_PROBLEMAREA L CONSTRUCT-ION.."SPECIFICATIONS"_ ¢ p� <br /> Industrial [T Kppen Bottom ❑Manteca E Dia. of Well Excavation i.tl `Qp <br /> Rmestic/Private ❑Gravel Pack ❑Tracy Dia, of Well Casing <br /> F + <br /> ` LL3 Public ❑ Other ❑ Delta Type of Casing y <br /> Irrigation Approx. ❑ Eastern <br /> Depth <br /> Specifications <br /> ❑Cathodic Protectio I- <br /> v ❑Geophysical Depth of Grout Seal <br /> A912 141W <br /> c� ❑Other Type of Grout <br /> 4 Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. 1 State Work Done <br /> Well Destruction Well. Diameter Sealing Material (top 501) <br /> Depth Filler Materjal (Below 50') - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONLJ; (No septic tank or seepage pit permitted if public sewer is <br /> '�I ' / available within 200 feet.) <br /> Installation will serve: ..Re'sidence _` Commercial Other <br /> Number of living units:; �} Number ofbedroomsLot size <br /> Character of soil to a depth of 3 feet:" Water table depth <br /> G SEPTIC TANK ❑, Type/Mfg 4 Capacity No. Compartments { . <br /> PKG. TREATMENT PLT. ❑ Type/Mfg ' I Capacity Method of Disposal <br /> SEWAGE SYSTEM f Distance to nearest: Well �� foundation Property Line <br /> DESTRUCTION Ca <br /> LEACHING LINE ❑ i No. & Length of line's Total length/size <br /> FILTER SED ❑ Distance to-nearest -:ZWell Foundation Property Line i <br /> f <br /> SEEPAGE-PITS -- -Fr­-Depth-❑". -Depth Srze� - -•-'--„ -'^-'Number -'" '4-- � -- ' rl —=•C3 <br /> SUMPS ❑ I! Distance to nearest: Well Foundation Pro perty"IL ine <br /> DISPOSAL PONDS ' <br /> Ii1 <br /> I hereby certify that I have prepared this application and that the work will be done i-_ac ordance withSan 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:.-jI certif-y-t•hat 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 workmans 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 emp persons, subject-to workman's compensation laws of California." <br /> The applicant pos all for all ire/ins,eections.' Complete dr g on r verse side. <br /> Signi Al Title: �� r Date: —� <br /> r FOR >P RTMENT USE ONLY ` ] <br /> 7ication Accepted by Area Stk 466-6781 <br /> Additional. Comments: * Lodi 369-3621 <br /> Pit or Grout Inspection by Date c3 Manteca 823-7104 <br /> Final Inspection by Date _` Tracy 835-b385 <br /> Applicant - Return all copies to: Environmental H aith Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO • <br /> 44 <br /> EH 13-24 REV. 10/82 10/62 500 <br /> 14-26 r <br />