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APPLICATION FOR PERE",'_T <br /> SAN JOAQUiN LOCAL HEALTH iiSTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 73 <br /> Telephone (209} 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,b <br /> 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 e San a n Leal Hea h District. <br /> Job Address � ^. f- Subdivision Name <br /> i Owner's Nam ¢ [lh�' Address . Phone -� <br /> k Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW! WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ( a, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V <br /> IU Industrial , U Open180ttom (] Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia, of Well Casing ¢" <br /> public ! <br /> Other Delta <br /> Type of Casing <br /> V Irrigation ' Approx. Eastern <br /> Depth Specifications <br /> Cathodic Protection r Depth of Grout Seal <br /> Geophysical <br /> U Other ts", Type of Grout <br /> F Surface Seal Installed by <br /> Repair Work Done Type 0f Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing'Material (top 50') <br /> Depth i Filler Material (Below 50') �. - " rz�4) I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is <br /> I xe_available within 200 feet.) <br /> Installation will serve: Residence 4 Commercial _ OtherCL L <br /> Number of living units: Number of drooms Lot size Zr <br />! Character of soil to a depth of 3 feet: 1;r _ Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments.: <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal, ' i <br /> SEWAGE SYSTEM <br /> DESTRUCTION 1 Distance!{to nearest: Well Foundation Property Line "- <br /> LEACHING LINE No. & Length of lines ` Total length/size 0 <br /> FILTER BED Distance to nearest: Well L Foundation Property Line <br /> SEEPAGE PITS, F-1 Depth Size Number + <br /> SUMPS PSI Distanceto nearest: Well Foundation Property Line <br /> DISPOSAL PONDS �1 <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 folioiding: :"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." i <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 emplo ns sub'ect to workman's compensation laws 0f California." <br /> The applica 11 or 1 r quir ct' ns. Complete drawing on reverse side. <br /> Signed Title: � Date: / <br /> { FOR EPARTMENT USE ONLY <br /> Application Accepted bye Area [� 5tk 466-6781 <br /> Additional Comments: l Lodi 369-3621 <br /> Pit or Grout Inspection by Date - Manteca 823-7104 f <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant.- Return all copies to: XEnVircnmertal i1alth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO IJ <br /> EH 13-24 REV. 10/82 10/82 .500 <br /> 14-26 <br />