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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE,, STOCKTON, CA PERMIT NO?3-3 1-7 <br /> 9 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE.ISSUED 5 3 <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 nd Re ulatio s of the San Joaquin Local-Halth District. �-7 <br /> Jab Address Ie e {�j j� Subdivision Name <br /> Owner's Name .t dress Phone <br /> Contractor's Name License No. Phone }2 / <br /> TYPE OF WELL/PUMP WORK: NEW WELL 0 WELL REPLACEMENT E DESTRUCTION <br /> II PUMP INSTALLATION E SYSTEM REPAIR OTHER ` 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE U3 <br /> -FOUNDATION 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `D <br /> Industria]' '� """ 8otto <br /> 0ent <br /> ❑ P Q-Manteca' Dia. of Well Excavation <br /> .J7 Domestic/PrivateQ Gravel Pack; Trac <br /> Public 1 y Dia. of Well Casing <br /> G Other ­ 0 Del to <br /> Lj Irrigation '�' t Type of Casing <br /> pry f <br /> �. Apox. I Q Eastern (� <br /> 0 Specifications Cathodic,Protection Depth %---i """"��^+ 4 <br /> Depth of Grout Seal <br /> Geophysical "� <br /> Lf Other Type of Grout <br /> Surface Seal Installed by (; <br /> Repair Work Done Type of Pump I i H.P. State Work Done <br /> Well Destruction U Well Diameter# Sealing Material (top 50') <br /> Depth ) Filler Material!(Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or see <br /> n• - .. ., _ g }�. A page pit permitted if public sewer is <br /> 'Installation will serve: Re is dente _� Commercial Other available-within 200 feet.) <br /> Number of living units: Number of bedroo s Lot size <br /> Character of soil to a depth of 31feet: <br /> SEPTIC TANK Water table depth <br /> Cj Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT..0 Type/Mfg E Capacity Method of Disposal <br /> Se tic Tank O Distance to nearest: Well Foundation Property Line <br /> Destruction <br /> LEACHING LINE U No. & Length of lines .Total length/size ; <br /> FILTER BED LW Distance to nearest: Well Foundation (;� Property Line <br /> SEEPAGE PITS'- ❑­ Depth 1 Size .. Number <br /> SUMPS U <br /> Distance to nearest: Well 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 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 becomeisubject to workman'; compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "T-certify that in the performance of the work f-or which <br /> this permit is issued, I shall employ persons subject to workman's compensation Taws of California." <br /> The applicant must call a required inspections. Complete drawing on reverse side. <br /> ..�Signed X 1 "' [ -� - ....y-��..�;.Title: <br /> ^" =n� Date: G <br /> F DEPARTMENT USE ONLY <br /> Application -Accepted by Aread� .Stk 466-6781 <br /> Additional Comments: [ . EJ Lodi 369-362.1 <br /> Pit or Grout Inspection �n _ <br /> Date � Manteca 823-7104 <br /> Final Inspection byDate L Tracy 835-6385 <br /> Applicant Return all copies toPermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE _,AMOUNT DUE- -AMOUNT REMITTED RECEIVED BY DATE <br /> INFOPERMIT N0. <br /> Al <br /> EH 13-24 REV. 10/82 <br /> 14-26 10/82 500 <br /> V <br />