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` EP ` APPLICATIONFOR PERM:T <br /> SAN JOAQUi?d LOCAL HEALTHi,ISTRICT <br /> r 1601 E. HAZELTON AVE,,. <br /> STCCKTON, CA PERMIT <br /> ;,x. :'; ] . O�I�L Telephone (209) 466-6781 3 <br /> , <br /> HEALTH <br /> _������N F�Js��RfCT DATE ISSUEDPERMIT EXPIRES 1 YEAR FROM 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,Health District. <br /> a <br /> Job Address ' LIMA <br /> ubdivision Name <br /> owner's Name tAfL Address Z H? hone Z�- g a <br /> Contractor's Name License No.ij <br /> Phone +* <br /> TYPE OF WELL/PUMP WORK: NEL! WELL [] WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �4g A ndustriad —U Open'Bottom- - 0 Manteca Dia. of Well Excavations <br /> Domestic/Private ❑Gravel Pack 7.Tracy Dia. of Well Casing <br /> Public [j OtherDelta Type of Casing <br /> Irrigation Approx. [L3 Eastern Specifications <br /> [h FI Cathodic ProtectionDepth <br /> _ i Depth of Grout Seal 1 <br /> E Geophysical s. Type of Grout <br /> other <br /> LI r Surface Seal Installed by <br /> ' Repair. Work Done ( J .Type of Pump J'___ H.P. "� State Work Done R:d Rf <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> — <br /> Installation will serve: Residence Commercial Other fff <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 E Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity - Method of Disposal ! <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> t DESTRUCTION <br /> LEACHING LINE U No. &'Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> s. <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS U Distance to nearest:-Well *Foundation s -- propertyYLine <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 /> i 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: "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 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 zemploy persons subject to workman's compensation laws of California." , <br /> The applican must ca for allrequired inspections. Complete dr wing on reverse side. <br /> Signed X . Title: Date' <br /> FOR <br /> ARTAKT USE ONLY 3 <br /> Application Accepted bStk 466-6781 <br /> yl Area <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection byDate Mante 23-]104' <br /> Final Inspection by lv! <br /> Date �]��_- Tracy. 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMDUNT DUE �AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> � # INFO <br /> 10/82 500 <br /> •EH 13-24 REV. 10/82 <br /> j 14-26 <br />