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APPLICATION FOR PERMIT <br /> * SAN JOAQUIN LOCAL HEALTH DISTRICT g�T <br /> 1601 E. HAZELTDN 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) k <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 Regulation of the San Joaquin Local Health District. ch <br /> S Job Address_ CL? <br /> / _ �} <br /> /\(:7�� ��tt��1 f7 P Subdivision Name <br /> Owner's Name 4 Z Address Phone 1 <br /> CContractor's Name �' / 'C' License No. ,,1 6 5::S- 9 V Phone ` 7 III <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [] DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial Open Bottom C]Manteca Dia, of Well Excavation <br /> L7 Domestic/Private Gravel Pack []Tracy Dia, of Well Casing <br /> 1-1 Public F-1 Other Delta <br /> Type of Casing <br />`Y U Irrigation Approx. 0,Eastern <br /> r ❑Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> Type of Grout <br /> Other Surface Seal Installed by <br /> Repair Work Done �J Type-of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> rTYPE Of SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION LI (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> f Installation will serve; Residence _ Commercial Other <br /> II Number of living units: Number of bedrooms Lot size <br /> ti Character of soil to a depth of 3 feet: Water table depth <br /> f SEPTIC TANK Cj Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method. of Disposal <br /> Distance to nearest: Well Foundation Property Line � <br /> LEACHING LINE F-1 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 ❑ _ <br /> I hereby certify that I have prepared this application and that the work wi 1 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 workmanl; 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." <br /> The applican m st C011 TOP-a1 fired inspections. Complete drawing on reverse side. �y <br /> Signed X Title: Date: If-' . !} <br /> c.. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Area Stk 466-6781 <br /> Additional Comments: Lodi 369-362.1' <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection byDate //—J Tracy 835-6385 <br /> Applicant - Return all copies to: EWironmental.Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t <br />( FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 140 <br /> EH 13-24 REV. 10182 10/82 500 <br /> 14-26 <br />