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i <br /> APPLICATION FOR PERMIT <br /> b <br /> SAN JOAQUiII LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE,, STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED _1 <br /> 5 (Complete in Triplicate) P /?p 72 <br /> Replication is hereby made to the San oaquin 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 the San Joaquin Local Health District. <br /> Job Address <br /> Subdivision Name <br /> Owner's Name L Address <br /> ,.� 'n.�.ZL+fa RW7 <br /> Contractor`s Name Phone <br /> License No. _eC� I Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK --JS',— SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial , U Open Bottom E] Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack -� <br /> LJ_ Trac of <br /> Public y Dia. of Well Casing _ <br /> [� Other Delta <br /> Lj.Irrigation Type of Casing {� <br /> Approx. � Eastern <br /> L] Cathodic Protection { Depth Specifications U >� <br /> D Geophysical Depth of Grout Seal <br /> LJ Other Type of Grout �+1 <br /> Surface Seal Installed by =:!raK t <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction Well Diameter � "Sealing Material (top 50'} <br /> µ <br /> Depth Filler Material (Below 501) L, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION <br /> LI 0 (No septic tank or seepage pit permitted if 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 Type/Mfg Capacity No. Compartments O <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal m <br /> SEWAGE SYSTEM <br /> DESTRUCTION Distance to nearest: Well Foundation Property Line <br /> ❑ <br /> LEACHING LINE U No, & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number f <br /> SUMPS L—I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 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 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-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issue I shall employ persons subject to workman's compensation laws of California." <br /> The app lica c f r ire Complete drawi rev side. <br /> Signed X Title: Date: <br /> R DEPARTMENT USE ONLY �G <br /> Applicatio ccepted t / Area 2— fZ1--Stk 466-6781 <br /> Additional Comments: 8 [] Lodi 369-3621 <br /> Pit or Grout Inspection Date Manteca 823-7104 <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant - Return all ccpie to: Envir nmental Health Permit/Services 160 E. azel cn®Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10182 10/82 500 <br /> 14-26 <br /> r <br />