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APPLICATION FOR .PERMiT <br /> SAN JDAQU;N LOCAL HEALTH DISTRICT <br /> 1602 E. HAZELTON AVE., STOCKTON, CA PERMIT N0, <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED�� <br /> (Complete in Triplicate) <br /> described. This application is made in compliance with San Joaquin County <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> Ordinance No. 549 for sewage or No, 1862 for well/pump <br /> and the Rul%Name Lat �rs of he San Joaoui Local Health District. <br /> Job Address _ � Subdi vision Name <br /> Owner's NamAddress 3 L _ ( ^Q Phone <br /> Contractor' 1" ivkLicense No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION <br /> F�J-' SYSTEM REPAIR OTHER U Obi. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS {f� <br /> eInd Tial U Open am Manteca Dia. of Well Excavation <br /> mestic/Privateravel Pack Trac V 1 <br /> y Dia. of Well Casing <br /> Public Other Delta ^" <br /> Irrigation Type of Casing ' <br /> ,Approx. Eastern <br /> ❑ Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> U Other <br /> Type of Grout <br /> (f Surface Seal Installed by <br /> Repair Work Done El Type of Pump S— H.P. <br /> I State Work Done ` <br /> Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') -� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION,U (No septic tank or seepage pit permitted if <br /> public sewer is <br /> Installation will serve: Residence _ Commercial _ Other available within 200 feet.) <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 Ej .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 �I <br /> LEACHING LINE IJ No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line �{ <br /> SEEPAGE PITS [j Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line } <br /> DISPOSAL PONDS C <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 workman compensation laws of California." <br /> Contractor's hiring or sub-co acting i'gnature certifies the following: "I certify that in the performance of the Work for which <br /> this perm9t, <br /> issu , I ha 1 e 1 sons bject to workman's co m nsation laws of California." <br /> The appliust 11 f 1 e i pe tions. Complete a 'non vgr si <br /> Signed X Title: C/.y. <br /> �. Date I <br /> F fl EjV SE ONLY Area C's Stk 46fi- 781 r <br /> Application Accepted by - VA <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection b Date ;2-Lr`r? Manteca 823-7104 <br /> Final Inspection by Date - ' ❑ Tracy 835-6385 <br /> Applicant - Return all copies to:. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEBASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />