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APPLICATION FOR PERMIT i <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209),466-6781 1 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete i n -Triplicate) ' <br /> Application is hereby made to the San-Joaquin Local Health District for a permit construct and/or install the work terein <br /> described. This application is made in compliance with San Joaquin County Ordi n e No. 549 for sewage or No. 1862 for well/putnp <br /> and the Rules a Re ulati ns o San Joaquin _Local Health District. <br /> �� f w <br /> Job AddressIA � <br /> 0 C .Subdivision Nam <br /> Owner's NamAddress Phone <br /> Contractor' o License No. <br /> Phone — 6U <br /> TYPE OF WELL/PUMP WORK: NEW WELL n/WELL REPLACEMENT 0 DESTRUCTION Lf - <br /> PUMP INSTALLATION 1,'yJ{ SYSTEM REPAIR 0 OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> kINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ (� <br /> industrial ❑ Open Bottom Manteca Dia. of Well Excavation <br /> �eXmestic/Private FIGravel Pack Tracy Dia. of Well Casing <br /> Public Other Delta Type of Casing <br /> u <br /> Irrigation A rox. Eastern g Depth � Specifications <br /> Cathodic Protection I Depth of Grout Seal <br /> Geophysical Type of Grout <br /> U Other , Surface Seal Installed by <br /> Repair Work Done Type of Pump CI" H.P. State Work Done <br /> Well Destruction L] Well Diameter Sealing Material (top 50') — <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORD: NEW INSTALLATION Ll REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> i available within 200 feet.) <br /> installation will serve: Residence _ Commercial _ Other <br /> Number of living units: I Number of bedrooms Lot size <br /> Water table depth <br /> Character of soil to a depth of.3 feet: <br /> SEPTIC TANK. F-1 Type/Mfg Capacity No. Compartments <br /> r PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> i <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION t <br /> I LEACHING LINE IJ No. & Length of lines Total length/size 1, <br /> !1 Foundation Property Line <br /> FILTER BED, � Distanc_e to 'nearest: Well <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS E <br /> I hereby certify that 1 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 followingance of the work far which this <br /> : "I certify that in the perform <br /> permit is issue I shall not employ any person in uch manner as to become subject to workman compensation laws of California."i <br /> Contractor's r ng or sub-contracting g ture c 'rtifies the following: "I certify that in the performance of the work for which <br /> this permit i sued, I shall employ s .hs sub//'ct to workman's ensat'on laws of California." <br /> i' The applic t m t c 11 f 1 requir d ec 'bns. Complete i g on reverse side. 7 <br /> Signed X <br /> Title: Date <br /> 0 EPARTMENT USE ONLY r Stk 466-6781 <br /> Application Accepted by Area _ �_ <br /> -" Lodi 369-3621 <br /> Additional Comments: <br /> Date Manteca 823-7104 <br /> Pit or Grout Inspection by <br /> {� <br /> D �} Tracy 835-5385 <br /> Final nspection by <br /> Applica�turn all copies to: Environmental Health Permit/Service 1 O1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMiT N0. <br /> INFO <br /> 3 <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />