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APPLICATION FOR.PERMIT <br /> SAN JOAQL'i?; LOCAL HEALTH 'DISTRICT f� , f <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 1 -5— y <br /> Telephone (209) 466-6781 <br /> DATE ISSUE C( <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> r <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 the San Joaq <br /> �uin Local Health District. <br /> Job Address ' 0 - / Subdivision Name <br /> �/ one..J�g s <br /> Owner's Name Address Z� tr`7 t� /L Ph ' <br /> �1 Phone <br /> Contractor's Name a p License No: <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER IJ 1 <br />'t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES w DISPOSAL FLD. PROP. LINE ` <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION`SPECIFICATIONS <br /> I J Industrial U Open Bottom 71 Manteca Dia. of Well Excavation V <br /> Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing k <br /> Public Other Delta Type of Casing . <br /> Li Irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> U Geophysical Type of Grout <br /> LJ Other Surface Seal Installed by e <br /> Repair Work DoneEl Type of Pump H.P. State Work Done j. <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth — <br /> DeP Filler Material (Below 50') <br /> C� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ DDITION I (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residen a u-,� Commercial _ Other <br /> t Number of living units: Number of bedrooms Lot size.5 �it�c�/ <br /> Character of soil to a depth. of 3 feet: Water table depth [� <br /> Capacity <br /> acity No. Compartments <br /> .s, SEPTIC TANK FJ <br /> P <br /> _PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> 1 SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION C] <br /> .. <br /> LL_A_CHING LINE No. & Length of lines Tota•1- length/size <br /> lL�[L'-TER BED ❑ Distance to nearest: Well ---.=fi'' Foundation --=�= Property Line <br /> SUMPS Distance to nearest: Well g—C, Foundation /�J�—Property Line ��_ <br /> D15POSAL PONDS ❑ �' ./ <br />,f I, hereby certify that I have prepared this application and that the1work-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 far which this <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmang compensation laws of California." <br />�- Cotl�tractor'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 /> .l <br /> The applicant t call for 11 required inspections. Complete drawing on reverse side. <br /> Signed X "'x-L Title: Date: <br /> ✓�" <br /> FOR DEPARTMENT_USE ONLY ' <br /> Application Accepted_,hy Are 5tk 466-6781 <br /> L' Lodi 369-3621 <br /> Additional Comments: <br /> Pit or Grout InspectiAn1Date U Manteca 823-7104 <br /> Final Inspection byDate <br /> (l Tracy 835-6385 <br /> Applicant -.Return all copier� mental Health Permit/Services 1601 E. H,zelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE SASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO 3 <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 1'4-26 <br />