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f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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) <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 Joaquin Local Health District. <br /> Job Address I L4 q 6 f kk., (40 Subdivision Name 1 <br /> Owner's Namee_11y t, Address (p Phone <br /> Contractor's Name lyJ ItLicense No. Phone ,,q:�7 <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION L] SYSTEM REPAIR OTHER <br /> DISTANCE 1O NEAREST.:—SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ "AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial U Oper Bottom EJ Manteca Dia. of Well Excavation + <br /> L_I Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing <br /> 0 Public F-1 0ther Delta Type of Casing <br /> V Irrigation Approx. Eastern Specifications + <br /> Cathodic Protection Depth Depth of Grout Seal <br /> 17 Geophysical '`" <br /> Type of Grout <br /> Other <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> Well Destruction 1K Well Diameter l Sealing Material (top 50') <br /> Depth 1,90 Filler Material (Below 50') <br /> SEPTIC WORK: NEW INSTALLATION f_1 REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Instal latl erve: Residence Commercial _ Other <br /> Number of living un Number of bedroomsLot size <br /> Character of soil to a depth oT 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 Foun a Property Line <br /> DESTRUCTION r <br /> LEACHING LINE U No. & Length of lines Total len ize <br /> FILTER BED Distance to nearest: Well Foundation Pr Line <br /> SEEPAGE PITS Cj Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <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 I <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California," <br /> The applicant m t call -for all required iQspections. Complete drawing on never a side. <br /> I Signed K Title: 1G('i 1 Date: <br /> FORDEPARTMENT USE ONLY <br /> Application Accepted by /} Area `� Stk 466-6781 <br /> Additional Comments: LD Lodi 369-3621 <br /> Pit or Grout Inspection by Date ID Manteca 823-7104 <br /> Final Inspection by _ e ❑ Tracy 835-6385 <br /> Applicant - Return all copies to; . En onmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 95201 <br /> FEE BASE AMOUNT.. DUE n AMOUNT,REMITTED- RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 3s-co -5_3Q-Ys. Sra—I z y7 <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 F <br />