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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <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 f the San Joaquin Local Health District. <br /> Job Address Subdivision Name ,,�� � �#3 �f Z& i <br /> Owner's Name # Address <br /> Phone <br /> Contractor's Name License No. 3 Phone _ S-//�•s <br /> TYPE OF WELL/PUMP WORK: NEW IWELL E/ WELL REPLACEMENT DESTRUCTION 3 <br /> PUMP INSTALLATION! SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK ! <br /> /QQ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 7 AGRICULTURE WELL OTHER WELL PITS/SUMPS �- y <br /> INTENDED USE 1 <br /> E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _S) ; <br /> 17 Industrial Open 1Bottom [] Manteca Dia. of Well Excavation �� <br /> f CirDamestic/Private [!?Gravel Pack Tracy Dia. of Well Casing <br /> Publ is Cj Other Delta <br /> Type of Casing love, F <br /> F1 Irrigation Approx. ❑ Eastern <br /> ❑Cathodic Protection Oepth Specifications <br /> Geophysical <br /> Depth of Grout Seal <br /> I—]Other Type of Grout — <br /> Surface Seal Installed by (� <br /> Repair Work Done Ef Type of Pump H.p. State Work Done ' <br /> Well Destruction U Well Diameter? Sealing Material (top 50') <br /> Depth k Filler Material (Below 50') <br /> I � ' <br /> TYPE OF SEPTIC WORK: NEW. INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> t Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of i feet; Water table depth } <br /> SEPTIC TANK CJ Type/Mfg . Capacity Na. Compartments i <br /> PKC. TREATMENT PLT. Type/Mfg , Capacity Method of Disposal ) <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Len 9th of lines Total length/size <br /> iE FILTER BED Distance'}to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS ❑ Depth 1 Size Number <br /> SUMPS U p Distance to nearest: Well Foundation Property Line <br /> r DISPOSAL PONDS EJ <br /> Ziak <br /> d <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 1 aws, 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, Ishall 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 /> E this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> E The applicant must call for al required inspections. Complete drawing on r erse side. <br /> Signed X LA 4uTitle: Date: / t7 <br /> I 1 EP TMENT USE PLY <br /> / �� Application Accepted.by ��/ Area 07 [] Stk 466-6781 <br /> j �4dditional Comments: ) [] Lodi 369-3621 <br />' Pit or Grout Inspection by Dat ''� / Manteca 823-7104 y <br /> k Final Inspection by Date racy 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 AMOUNT DUE AMOUNT REMITTED R€CEIVED BY DATE PERMIT NO. <br /> INFO <br /> 00 <br /> t EH 13-24 REV. 10/82 10/82 500 s <br /> 14-26 L/ <br /> _0 <br />