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t <br /> } APPLICATION FOR PERMIT + <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON,.CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM 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 workherein ' <br /> described. This application is madelin compliance with San Joaquin County Ordinance No. 549 for sewage or No.. 1862 for well/pump I <br /> and the Rules and Regulation of theSan Joaquin Lo 1 Health District. <br /> Jab Address (3 LL d Subdivision Name <br /> Owner's Name Address _ Q e- Phone -- <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL. UMP WDRK NEW WELL WELL REPLACEMENT ] DESTRUCTION ❑ <br /> PUMP INSTALLATION a SYSTEM REPAIR OTHER [� <br /> DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES DISPOSAL FLD. AW PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER'WELL PITS/SUMPS4142- <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; <br /> Industrial ❑ Open Bottom F-1 Manteca Dia. of Well Excavation ' tt { <br /> Domestic/Private El Gravel k.Pack Tracy Dia..of Well Casing <br /> Public F1 Other ❑ Delta Type of Casing <br /> [j Irrigation 32 a Approx. Eastern <br /> `" <br /> Cathodic Protection Depth SpecificationsI—I <br /> Depth of Grout Seal <br /> Geophysical <br /> LJ Other ` Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump 511� W.P. State Work Done <br /> Well Destruction U Well Diameter ' _ Sealing Material (top 501) <br /> Depth d® Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION L_1 (No septic tank or seepage pit permitted if 'p€iblic sewer is <br /> available within 200 feet.) y <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Cj Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> Septic Tank Distance, to nedrest: Well Foundation Property Line <br /> :Destruction 1.!0,��L <br /> LEACHING LINE,. E] No. & Length of lines Total length/size r <br /> crILTER BED U,, Distance to nearest: Well Foundation Property Line <br /> SEEPAGE=PITS Depth . — _-Si-ze­-- <��__==— —.�-Number� <br /> SUMPS ' LI 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'haws,—and-yrules and regulations of the San Joaquin focal Heal tM'District. <br /> Home owner or licensed agent's signature certifies the following: "%.certify that Ori the performance of the work for which this <br /> permit is issued, I shall not employ any person in such manner as to become_sd6ject-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 applica must call f r all uir�ed inspections. Complete drawing on reverse side, <br /> �si <br /> Signed X._ZJ Title; Date: <br /> ! P N USE ONLY <br /> Application Accepted by Area Stk 466-6781 <br /> Additional Comments: t_,., O_Lodi T 369-3621 <br /> Pit+or-Grout-InspectiWby, Date El Manteca-823-7104 i <br /> Final Inspection by Date i ❑ Tracy 835-6385 <br /> Applicant Return all copies to: Enviro mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO y <br /> -K3 <br /> EH 13-24 REV. 10/82 •�' ; ; 10/82 500 <br /> 14-26 <br />