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w APPLICATION FOR PERMIT <br /> 4 <br /> 3 N� <br /> SAN JOAQ1L211 LOCA! HEALTH DISTRICT <br /> 1601 E. HAZELTON AVL., STOCKTON, CA PERMIT NO. <br /> Telephone (204) 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 i <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> -land'the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address Subdivision Name <br /> Owner's Name //k _ �j`t ft1T Address Phone 1 L 1 <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL [ �WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER Lj <br /> DISTANCE TO NEAREST: SEPTIC TANK 1Q f7 SEWER LINES J 5_t�. DISPOSAL FLO. PROP. LINE C> <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i or <br /> Fj,Industrial [+.-&Pen Bottom Manteca Dia. of Well Excavation <br /> -10mestic/Private Gravel Pack U Tracy Dia. of Well Casing <br /> 17 Public LJ Other Delta Type of Casing _ F.-, -e- L <br /> Ll Irrigation Approx. Eastern <br /> Depth Specifications <br /> Cathodic Protection Depth of Grout Seal <br /> Geophysical <br /> Type of Grout _q-�> -- �-_1\ <br /> jJ Other <br /> Surface Seal Installed by <br /> Repair Work Done G Type of Pump 4.•. b H.P. State Work Done <br /> Well Destruction LJ Well Diameter Sealing Material (top 50') _ <br /> i <br /> Depth Filler Material (Below 50') <br /> 4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> ]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. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE ❑ 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- -- �- --L:I-'�'Distarice—to n�-arest:''Well Foundation-+ - --Property-.Line --A <br /> DISPOSAL PONDS Cl <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 workmant 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 applicant must call for all required inspections. Complete drawing on reverse side. / <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ON Y —� �I <br /> Application Accepted by Area +� Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection Date Manteca 823-7104 <br /> Final Inspection by Date Tracy 836-6385 <br /> Applicant - Return all copies to: mental Health Permit/Services 16 1 F. azelt n Ave., P.O. Box 2009, St k., CR 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO gLi <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 \�a� , <br />