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isc's PEiO I j <br /> APPLICATION FOR PERMIT � <br /> SEP 191M SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 3 tea l� <br /> SM JIAQuin 1 n Telephone (209) 466-6781 : _ DATE ISSUED "k <br /> WEALMIA PERMIT EXPIRES 1 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 Joaquin County Ordinance-No. 549 for sewage or No. 1862 for well/pump <br /> and:the Rules and <br /> ••��Regulations of he Sag Joaquin_La al Health' District. <br /> Job Address O�0 �Sro S t Subdivision Name <br /> Owner's Name Address Phone <br /> Phone <br /> Contractor's Name S D License No. <br /> TYPE OF WELL/PUMP WORK: NEW WELL F] WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ---- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS d <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Public Other Delta Type of Casing <br /> LjirrigationApprox. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical Type of Grout <br /> Other Surface Seal Installed by <br /> Repair Work Done Type of Pump - H.P. `"°a "State Work Done RoAr.". (iP <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit <br /> available permitted <br /> if piublicfsete) is <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 [1 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. F-1 Type/Mfg <br /> s Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ! <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITSDepth Size Number <br /> SUMPS �� Distance to nearest: Well Foundation. Property Line <br /> 4 <br /> DISPOSAL PONDS ❑ ~i <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. Y <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 workmank compensation laws of California." <br /> E Contractor's hiring or sub-contracting signature certifies the following: "I certify that,in the performance :f .the work for which <br /> - this permit is issued, I sh ll employ persons subject to workman's compensation laws of California." <br /> The applica mus call a re wired inspections. Complete drajing on reverse side. �� <br /> Signed X <br /> Title: [��(j�—�-- Date: <br /> 3 ENT U LY Stk 466-6781 <br /> Application Accepted b Area Q�O <br /> + Lodi 369-3621 <br /> Additional Comments: � Manteca 823-7104 <br /> Pit or Grout Inspection by Date <br /> iDate ❑ Tracy 835-6385 <br /> Final Inspection by <br /> Applicant - Return all copies to: Environmental1Iealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5t k., CA 95201 <br /> { DATE PERMIT NO. <br /> FEE BASL AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFO �A �� � 9 <br /> 10/82 500 <br /> { EH 13-24 REV. 10182 ~] <br /> (` �, 14-26 l -- — <br />