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APPLICATION FOR PERMIT <br /> SAN JOAQU;N LOCAL HEALTH Dw4kr <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466=6781 <br /> PERMIT EXPIRES I YEAR DATE ISSUED <br /> FROM DATE ISS)l <br /> (Complete in Triplicate) 0",Sl <br /> Application is hereby made to the San Joaquir Local Health District for a permit to construct and/or install the work <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 forherein well/pump <br /> and the Rules and Regulations of te San Joaquin Lo al Health District, <br /> Job Address--[ —_W 70 I A,, Subdivision Name <br /> Owner's Name Addrets -14%t 6, <br /> nef' PDO It Phone <br /> Contractor's Name -MiLER, License No. A Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR L OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f—] Industrial 0 Open Bottom EJ Manteca Dia. of Well Excavation <br /> �stic/Private Ej Gravel Pack EJ Tracy Dia. of Well Casing <br /> Public Other Delta <br /> Irrigation Approx. Eastern Type of Casing <br /> Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> Lf Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done 2'--Type of Pump E5 H.P. State Work Done <br /> Well Destruction Ej Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION FJ_ REPAIR/ADDITION E) (No septic tank or seepage pit permitted if public sewer is C. <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 <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> F DESTRUCTION ❑ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Ej— Depth _ Size Number <br /> SUMPS LJDistance 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 theperformance of the work for which this <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmancompensation 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 issued, I Shall employ persons subject to workman's compensation laws of California." <br /> The applicant call f e uir d ins7 ecti . Complete drawl 2Q on reverse side. <br /> , <br /> Signed X Date: <br /> T E ONLY <br /> Application Accepted y Area 0 E] Stk 466-6781 <br /> Additional Comments [] Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> b Final Inspection by Date Tracy 835-6385 <br /> Applicant - Return all c ie o: nvironmentafr`Health Permit/Service's 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. 1.0/82 10/82 500 <br /> 14-26 <br />