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APPLICATION FOR PER1F,1,7 n] _ <br /> SAN JOADUIN LOCAL hEALTH DISTRICT V���'I <br /> k <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 3 3 <br /> Telephone (209) 466-6781 <br /> f 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 S n J <br /> Jokquin Local Health District, <br /> Job Address �� OW. <br /> �"'r'_ Subdivrri��sion Name <br /> Owner's Name / Address /y� / Phone�lfitJ' <br /> Contractor's Name _ > -•- y <br /> License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION STEM REPAIR OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK R LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS fll' <br /> INTENDED USE Tav <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS V�^ <br /> 17 Industrial VG <br /> E Manteca Dia. of Well ExcavationU Domestic/Private ❑ Tracy Dia. of Well Casing <br /> 17 Public D DeltaL1Irrigation Type of Casing <br /> � Eastern <br /> Cathodic Protection Specifications <br /> Geophysical Depth of Grout Seal <br /> ❑Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION b­ej (No septic tank or seepage pit permitted if public sewer is _! <br /> Installation will serve: Residence Commercial Other available within 200 feet.) -� <br /> Number of living units: ! Number of bedrooms Z— Lot size 3 APS <br /> Character of soil to a depth of 3 feet: Water table depth m <br /> SEPTIC TANK Ej Type/MfgCapacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to <br /> ne rest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines Total length/size 4 <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth 25 Size 5; Number <br /> SUMPS L Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Q <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 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 employ persons subject to workman's compensation laws of California." j <br /> The applicant must call for all required inspections. Complete drawing n reverse side. <br /> Signed X <br /> Title: G -__ Date: <br /> EO SPAR (ENT USE ONLY V <br /> Rppl ation Ac ted by Area d-� � Stk 456- <br /> Additional Comments: _ Lodi 369-3621 <br /> Pit or Grout Inspection by Date _S 3 U Manteca 823-7104 <br /> 11 <br /> Final Inspection by Date Trac 835-6385 <br /> :�3 u y <br /> Applicant - Return all co to: Environ tal aIth Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 ' <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH I3-24 REV. 10/82 10/82 500 <br /> 14-26 44 a-0 <br />