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r_ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT {� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. d 7 <br /> Telephone (209) 466-6781 <br /> _ DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v <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 /> L. 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 id Regulations of the San Joaquin Local Health District. <br /> Job Address ( ��,� Subdivision Name <br /> Owner's Name ° 1 <br /> Address p <br /> Contractor's Name '� LC4 Phone <br /> License No. Phone <br /> 4 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> L PUMP INSTALLATION SYSTEM REPAIR OTHER EJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> LFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> _ IFl Industrial U Open Bottom []Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private Gravel Pack E]Tracy Dia, of Well Casing <br /> 4 ❑Public EJ Other Delta <br /> lrri Type of Casing <br /> L 9ation Approx. Eastern Specifications <br /> i E]Cathodic Protection Depth <br /> []Geophysical Depth of Grout Seal <br /> Other <br /> Type of Grout <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 /> TYPE OF SEPTIC WORK: NEW INSTALLATION TJ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is S <br /> Installation will serve: Residence _ Commercial _ Other aw <br /> available within 200 feet.) S <br /> Number of living units: 0 _ Number of bedrooms ��----- Lot size <br /> ( Character of soil to a depth of 3 feet:ift _J[ ,.ya� Water table depth 5!1 n7 <br /> SEPTIC TANK [] Type/Mfg `� Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> 1 L Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE [J No. E Length of lines Total length/size <br /> FILTER BED E] Distance to nearest: Well /av Foundation Property Line <br /> 1 <br /> SEEPAGE PITS [] Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> LI 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 workmank compensation laws of California." <br /> V 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 applicanl;,myss call r ll required inspections. Complete drawing on reverse side. <br /> Signed X C -- -- �9902:7(((��� ���JJJ{� Title: 06&^,L,? Date: <br /> , ftTME�T USE ONLY Area <br /> Application Accepted by r }�_ Stk 466-6781 <br /> LAdditional Continents: 0 Lodi 369-3621 <br /> LPit or Grout Inspection by Date Q Manteca 823-7104 <br /> Final Inspection by /���/ Dater Tracy 835-6385 <br /> L Applicant - Return all copies to: Environmen HealthT Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED MRECEIVED DATE PERMIT N0. <br /> INFO <br /> �Jm / a3 � - 7.? <br /> EH 113-24 4-26 REV. 10/82 �`,-l" 12(/ f, f 10/82 500 <br />