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APPLICATION FOR PERMIT Otto— <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> a <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 RuljandRegulati of the San Joaquin Local Health District. <br /> Job Addres . Subdivision Name <br /> Owner s NamAddress ell— `JIt Phone <br /> Contractor' ' z License No. - Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT � DESTRUCTION EJ <br /> w <br /> PUMP INSTALLATION (] SYSTEM REPAIR OTHER 0 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom E]Manteca Dia. of Well Excavation <br /> Domestic/Private 0 Gravel Pack Tracy Dia. of Well Casing <br /> Public F-1 Other Delta <br /> Lj Irrigation Approx. E] Eastern Type of Casing <br /> Cathodic Protection Depth Specifications <br /> Ll Geophysical <br /> Depth of Grout Seal <br /> F-IOther Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done [J Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Vf REPAI DD TION (No a is tank or seepage pit permitted if public sewer is <br /> ``t _�e' available within 200 feet.) - <br /> -installation will serve: Residence X Commercial _ Other <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 �'j Type/Mfg 6 1 C Capacity ` Z t2 U No. Compartments 7 <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> �� <br /> Distance to nearest: Well &,4 oundation Property Line ✓ c{ T <br /> LEACHING LINE No. & Length of lines a — (r 1,,14— Total length/size C — <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITSLLJ Depth 4' Size " Number <br /> J � <br /> SUMPS F <br /> I Distance to nearest: Well J(A tj—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 /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant st call for all r jired inspections. Complete dra g on reverse side. <br /> Signed X 4c° Title: Date: —�� � <br /> � DEftT U E ONLY <br /> Application Accepted by Area Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by -Z1�, t Date Manteca 823-7104 <br /> Final Inspection by �,� ��,, --- Date Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 16dl 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 /> `� 13 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />