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--� APPLICATION FOR PERM.T n+�IIID <br /> SAN JOAQUi's LOCAL h'E .LlH D';SiRICT \ $,S-lost (J4 <br /> 1501 E. HAZELTON AVE., STUCKTON, CA �� 9PMUED <br /> [Vt,,eTelephone (209) 466-6781 \\ Jj - ` fPERMIT EXPIRES 1 YEAR FROM DATE ISSUED R 1,� - 3P <br /> (Complete in Triplicate) - �7 <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 RegulatioGns, of the San Joaquin Local Health District. i <br /> Job,.Address U- <br /> Owner's Name r <br /> Address Phone <br /> :Contractor's Name Li ense No. r <br /> Phone <br /> >TYPE OF WELL./PUMA WORK: °I�° NEW WELL WELL REPLACEMENT F-1 DESTRUCTION ❑ <br /> PUMP INSTALLATION J-} SYSTEM REPAIR 0— OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK r_ SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDR.TION AGRICULTURE WELL OTHER WELL PITS/SUMPS r- <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 2--1 <br /> �-Isstt <br /> ria] U Ope Bottom ]Manteca Dia. of Well Excavationc/Private ravel Pack Tracy Dia: of Well Casing {1 <br /> Public Other Delta <br /> VIrrigation Type of Lasing <br /> 9 Approx. Eastern Specifications <br /> Q Cathodic Protection Depth P <br /> Geophysical ��i Depth of Grout Seal <br /> --�' <br /> Other \ i Type of Grout <br /> Surface Seal Installed by —� <br /> Repair Work Done F] Type of PumH.P. State Work Done <br /> Well Destruction U Well Dp Diameter Sealing Material (top 50') <br /> o _ <br /> Depth Filler Material (Below 50') <br /> ilTYPE OF SEPTIC WORK: NEW INSTALLATION R A <br /> IE� EP IR/ADDITION seepage pit permitted if public sewer is <br /> LI LJ (No septic tank or see a e <br /> " <br /> I available within 200 feet.) <br /> I Installation will serve: .:'Residence Commercial Other - <br /> Number of living units. ii Number of bedrooms Lot size <br /> E Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG., TREATMENT PLT. [f Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> I DESTRUCTION If <br /> LEACHING LINE U No. & Length of lines Total length/si•ze <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Cj Depth Size Number <br /> s , <br /> SUMPS Ll 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, andirules 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 t e fallowing "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to wor n's compensation laws of California." <br /> The appiican ust call for 17 require inspect' s. m 1 e drawin on reve a si e. .� <br /> Signed X _ Date: <br /> 0 SE ON <br /> 0 Application Accepted:by Area Q/ Stk 466-6781 <br /> I !Additional Comments: <br /> E Lodi 369-3621 <br /> Pit or Grout Inspection Date anteca 823-7104 <br /> Final Inspection by j� Date ❑ Tracy 835-6385 <br /> Applicant - Return all copie to: . Envir mental ea th Permit/Services 1601 Haz lton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> SEH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />