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0 <br /> APPLICATION FOR_PER.MIT <br /> SAN JOAQUiN LOCAL HEALTH-DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 I ' <br /> jl DATE ISSUFO <br /> .�.w... 3 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in- Triplicate) <br /> I <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 Rulesu at' ns„Qf t e an J in Local Health District. <br /> Job Address I !, Subdivision Nam <br /> Owner's Name r Addressft sl Phone <br /> Contractor's NameLicense No. Phone <br /> 1 <br /> TYPE OF WELL/PUMP WORK: NEW WELL LL REPLACEMENT DESTRUCTION U J <br /> PUMP INSTAL LA / SYSTEM REPAIR OTHER L✓J _ s <br /> DISTANCE TO NEAREST: SEPTIC TANK !F�SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. <br /> J Industrial pen Bottom Manteca Dia. of We <br /> 11 Excavation ! <br /> L} Domestic/Private []Gravel Pack ❑ Tracy Dia, of Well Casing <br /> Pu c Delta I <br /> r �,--.C1 Other � Type of Casing „7♦ <br /> rlr�gatiorid � Approx. Eastern <br /> 4 <br /> F-1CathodicProtection A-4 <br /> Depth Specifications <br /> Depth of Grout Seal -.--_ <br /> Geophys-i ca l;: <br /> Type of Grout d <br /> Other ll_•edt' by. <br /> (' l Surface Seal Insta <br /> Repair Work Done [JType of Pump[ " H.P. State Work Dane #+ <br /> Well Destruction ❑ Well Diameter 5: J �} Sealing Material (top 50') � <br /> R , <br /> Depth i Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is. ]b <br /> �+ *- --�_-,---- M available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other 'X ' <br /> Number of living units: i Number of bedrooms Lot size w <br /> Character of soil to a depth"of 3 feet: Water table depth W i <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> E SEWAGE SYSTEM Distance to-nearest-, Well Foundation Property Line <br /> DESTRUCTION ❑ ! ) <br /> LEACHING LINE U No. & Length of lines cTotal length/size <br /> ,3 I <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS Distance to nearest: Well I Foundation Property Line ,. <br /> 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 Local Health District. <br /> Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this <br /> .permit_ is issued, I shall employ any person in such manner as to become subject to workmans compensation laws of California." <br /> Con tractor's'hiring`or u -6 -g sign tu`re certifies"the"folfowi'ng:"1,,certify-that-in-the•-performance-of--the work-fon-which -� <br /> this permit s i sued a m 0 ers s ubject to,workman's co ens ation�laws of California." <br /> The applic m s c 1 f i t pe tibns. JComplete dr n ion, r s V v <br /> w . Signed X r - .7itle:.,. Date:. <br /> 13 FOR DEPARTMENT USE ONLY <br /> Application Accepted by Area Q �Stk 4fi6-6781 <br /> Additional Comments: [] Lodi 369-3621 <br /> Pit or Grout Inspecti;;�tVby Date Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copieo: Envir mental Health Permit/Services 1 0 F. H Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO.INFO b 11-meq <br /> ]] <br /> i f'Z� ►1-753 <br /> I EH 13-24 REV.' 10/82 10/82 500 <br /> L; <br /> 14-26 <br />