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i <br /> APPLICATION FOR PERMIT i <br /> SAN JOAQuIN LOCAL HEALTH DISTRICT pERhIII N0. <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 DATE ISSUED T <br /> PERMIT EXPIRES 1 YE.AR. FROM DATE ISSUED <br /> (complete in Triplicate) <br /> l the <br /> rein <br /> Application is Joaquinth countypernit 0 dinanccecNno. 549 fordsewageSorlNo. 1862rforewe11/pump <br /> described. This app <br /> and the Rules <br /> and Re Mations of t San a in �,ocal Health District. <br /> I Subdivision Name <br /> Job Address ] <br /> _Phone <br /> Owner's Name. Ad dr ss <br /> • Phone <br /> i nse No. <br /> Cent Name <br /> Name <br /> i <br /> TYPE OF WELL/.PUMP WORK: NEW WELL WELL REPLACEMENT <br /> DESTRUCTION <br /> U <br /> PUMP INSTALLATION �SYSTEM REPAIR MER <br /> PROP. LINE <br /> SEWER LINES DISPOSAL FL9. <br /> DISTANCE TOINEAREST: SEPTIC TANK __-,_�,_�. OTHER WELL PITS/SUMPS <br /> I� FOUNDATION AGRICULTURE WELL <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDD USE TYPE OF WELL PROBLEM AREA Dia. of Well Excavation <br /> FlIndustrial <br /> U Dpen Bottom Manteca <br /> Trac Dia. of Well Casing <br /> L ) <br /> Domestic/Private Gravel Pack [3Y <br /> Public Other Delta Type of Casing <br /> V <br /> Irrigation Approx. [}Eastern Specifications <br /> FJ Cathodich Protection � <br /> Depth Depth of Grout Seal <br /> Geophysical Type cf Grout <br /> F-1 Other ' Surface Seal Installed by <br /> H P State Work Done <br /> Repair Worki �...+�r-- - <br /> Done Type of Pump _ # <br /> 'Sealing,Material'(top 50') <br /> Well Destruction U Well Diameter <br /> Depth Filler Material (Below 50')— <br /> N — {No septic tank or seepage pit permitted if public sewer is '� 1 <br /> LJ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION �REPAIR/ADDITSO available within 200 feet.) <br /> '�1 I _ Other <br /> Installation will serve: Residence i / commercial <br /> I t t size <br /> Number o1 01 <br /> hf living units: Number of bedrooms Water table depth <br /> charact hr of soil to a dept of 3 feet: „ ,.,x,+ capacity No. Compartments <br /> I SEPTIC TANK [ � Type/Mfg Capacity r"�+^`"" 'Method{of isp45g1 <br /> PKG. TREATMENT PLT. Type/Mfg -~�~ <br /> SEWAGE SYSWell TEM Distance to nearest: <br /> Foundation Property Line <br /> DESTRUCTION <br /> Total length/size ; K <br /> LEACHING KNo. & Length of lines INE U Foundation l] -Property Line <br /> FILTER BED Distance to nearest: Well <br /> Depth Size <br /> Number <br /> SEEPAGE PITS ❑ p Foundation Property Line � n <br /> SUMPS i �� Distance to nearest: Wella ? • ' <br /> ( DSSPOSALI PONDS <br /> II � r <br /> plication and that the work will be done in accordance with San Joaquin county .. <br /> I hereby:1certify that I have prepared this app erformance ofthe.work for which this <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Hethat in <br /> * i <br /> Home owner or licensed agent's signature certifies the ollowing: "I certify compensation laws of California." ` <br /> permit is issued, I shall not employ any person in such manner as,to become subject to workmathe nh <br /> Contractor's hiring or sub-contracting signature crifies the follcompensationwing: rlaws oftify aCalTiforniaerfor once o the work for which <br /> this permit is issued, I shall employ persons subject <br /> r <br /> +. <br /> The applicant ust all for al wired inspections. Complete drawing on reverse side, Date: <br /> Title:' <br /> Signed X� <br /> f� FffilDEPA DEPARTMENT USE ONLY Stk 466-6781 <br /> Area <br /> Application Accepted by Lodi 369-3621 <br /> o. <br /> Additional Comments: Date Manteca 823-7104 <br /> I Pit or Grout inspection b Date Tracy 835-6385 <br /> i <br /> 1Final Inspection by <br /> Applicant - Return all copies o: . Environmental Nealth Permit/Services 5201 <br /> 16 E. zelton Ave., P.D. Box 2009, 5t k., cA. 9 <br /> IMRECEIVED BY DATE PERMIT NO. <br /> F4EE BASE AMOUNT DUE AMOUNT REMITTED <br /> FO <br /> �`� � ! r 10/82 500 <br /> EH 131`24 REV. 10/82 <br /> 14t26 <br />