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APPLICATION FOR PERMIT <br /> SFN JOAQU;,; LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> 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 Regulations of the San Joaquin Local Health District. <br /> Job Address I I I I)1�1,— Subdivision Name <br /> Owner's Name R "DEL1 S Address D Elia L1 Phone (fl <br /> W L� 4 Phone <br /> Contractor's Name License No. P 0 <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION X SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST:_ SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP. LINE } <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> U Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing j <br /> Public [—I Other Delta Type of Casing ! <br /> L Irrigation Approx. Eastern Specifications _ <br /> Cathodic Protection <br /> [� Depth Depth of Grout Seal S} <br /> ❑ Geophysical Type of Grout <br /> U Other Surface Sea aby <br /> Repair Work Done ) Type of Pump �ua H.P. L. State rk Done R�edX-- € Ht," R w <br /> Well Destruction Lj Well Diameter Sealing Material (top 50') — <br /> Depth Filler Material (Below 60') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION U (No septic'tank or seepage piavaermitted ifpublic <br /> thin 200fseter is <br /> ilable 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 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. U Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <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. <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 workmans compensation laws of California." <br /> Contractor's iring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I sh 1111 employ rsons bject to workman's compensation laws of California." <br /> The applican us t call fowl r i e -nspe ions. Complete dr win on reverse side. <br /> Signed X <br /> Title: r Date: <br /> F R DEPARTMENT USE ONLY -�`� �tk 466-6781 <br /> J 4—q— <br /> Application Accepted by 'y_ Area �.� <br /> F r-] Lodi 369-3621 <br /> Additional Comments: <br /> Pit or Grout Inspection Date Manteca 823-7104 <br /> A� Date ❑ Tracy 835-5385 <br /> Final Inspection by `1J� <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO -t.3 <br /> �5 • 00 <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />