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APPLICATION FOR PERMIT �dam' <br /> � <br /> SAN JOAQLIP! LOCAL HEALTH 'DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. C 21-1 <br /> Telephone (209) 466-6781 e <br /> DATE ISSUED <br /> � �,,r�\N 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 / 0 a Subdivision Name <br /> Owner's Name i FN- Address Phone <br /> Contractor's Name LiLj--. License No. / 4 Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL F� WELL REPLACEMENT DESTRUCTION Ef <br /> PUMP INSTALLATION (] SYSTEM REPAIR L7 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS oLJ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial U Open Bottom F-1 Manteca Dia. of Well Excavation I <br /> Domestic/Private F-1 Gravel Pack ❑ Tracy Dia, of Well Casing ) <br /> 17 Public [-1 Other E] Delta L, <br /> Type of Casing <br /> Lj Irrigation Approx. Eastern <br /> Depth Specifications �✓ <br /> F-1CathodicProtection t <br /> Depth of Grout Seal <br /> ❑Geophysical <br /> Type of Grout <br /> U Other <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> C� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION F-1 (No septic tank or seepage pit permitted if public sewer is +� <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other <br /> �- _ <br /> Number of livingml Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: F Water table depth <br /> SEPTIC TANK Type/Mfg °tij Lj'1 Capacity _ No. Compartments �1 _ <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION U <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well ' Foundation Property Line <br /> SEEPAGE PITS Depth ] Size Number <br /> SUMPS L-1 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 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 ermit is iss ed, I s 11 employ persons subject to workman's compensation laws of California." <br /> The applic t al X11 e red inspections. Complete drawing o revers side. 7 <br /> -- <br /> Signe + Title: '> c �` Date: <br /> FO ARTMENT USE ONLY <br /> Application Accepted by Area _ 3Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection b Date ( Manteca 823-7104 <br /> Final Inspection by Date ��/� " ❑ Tracy 835-6385 <br /> Applicant - Return all c to: Environmental Health Permit/Services 1601 E. Hazelton 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. 10/82 I <br /> 10/82 500 <br /> 14-26 i T i$( J <br />