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f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH ,DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. rQ <br /> Telephone (209) 466-6781 <br /> DATE ISSUED r <br /> PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the an 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 Regul ions of the San Joaquin Loth;District. <br /> ,lob Address Subdivision Name <br /> Owner's Name / Address Phone »{J�p(� <br /> Contractor's Name License No. .C,%9�2� Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL j" WELL REPLACEMENT DESTRUCTIONIch <br /> ❑ OCl <br /> PUMP INSTALLATION SYSTEM""REPAIR ❑ OTHER U W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLO. PROP. LINE 1 <br /> FOUNDATION iAGRICULTURF WELL OTHER WELL PITS/SUMPS C1J <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial U Open Bottom",`:rs� Manteca Dia. of Well Excavation <br /> Domestic/Private ! Gravel Pack_ .` ,Tracy Dia. of Well Casing <br /> Public �❑ Other ❑ Delta ��� �� ' <br /> Type of Casing <br /> L Irrigation ;Approx. ❑Eastern <br /> Specifications <br /> Cathodic Protection <br /> Depth <br /> # Depth of Grout Seal <br /> 1­1 Geophysical <br /> ., Type of Grout <br /> U Other, <br /> Surface Seal Installed by_ JprQ/L. <br /> Repair`"Work Done D Type"of Pump k''H• P State Work Done <br /> Well�,Destruction U Well Diameter; Sealing Material (top 50') _ ,J <br /> Depth I _.hs" "FiTler'Material (Below 50') OL} <br /> F TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> A' ! 3 . available within 200 feet.) <br /> lnstal`lation will s rve:"•r Residence +� Commercial Other <br /> INumber of living units: Number of bedrooms' Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑j Type/Mfg} a Capacity No. Compartments <br /> PKG. rTREATMENT PLT. U Type/Mfg i • Capacity Method=df`Disp 1 <br /> SEWAGE SYSTEM I, I� Distance�to'nearest: Well Foundation - Property Line <br /> DESTRUCTION, l__1 _ <br /> LEACHING"-LINE* ❑ No. & Len gth:.of—l:ines- x Total length/size <br /> t — <br /> FILTER BED � rDi'stanc'e ,to nearest: Well Foundation Property Line <br /> 14 SEEPAGE PITS Depth Size ,Number <br /> SUMPS 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:rul-6eVand regulations of the San Joaquin Local Health District. <br />� <br /> r k f Home owner or licensed agent's signature certifies the .ollowing. I certify that in the performance of the won r which this o <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 /> thi,s .permit.is issued, I shall employ persons subject to workman's compensation laws of California." <br />` The applican t cal] f all equir�insp,ekons Complete drawing on'®reverse side. �+ <br /> Signed x x '+Tit le:. <br /> FOBeDEPAPWENT USE ONLY <br /> Application Accepted by Area 4:07 ❑ Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> 14 <br /> Pit or Grout Inspection by Date �- 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, 5tk„ CA 95201 <br /> " x t <br /> FEE BASE AMOUNT DUE ,�:,:Y, ,". "AMOUNT REMITTED ''/` RECEIVED BY DATE �PERMIT N0. <br /> INFOf;V , 7 <br /> r <br /> EH 13-24 REV. 10/82 "^" - 10/82 500 ' <br /> 14-26 <br />