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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL`HEALTH DISTRICT �Q �s <br /> 1601 E. pAVE., STOCKTON, CA PERMIT N0: -3 Q <br /> Telelephonehone (209) 466=6781 <br /> T PERMIEXPIRES 1 YEAR FROM DATE ISSUED' <br /> DATE ISSUED I L kge <br /> SAN J QUIN LOCAL <br /> HEALTH ®ISTR1�Y (Complete in Triplicate) <br /> t Application is hereby made to the San Joaquin Local Health District for a�lpermit 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 Rules and Regulations of the'San Joa Or Local Health District. <br /> Job Address Subdivision Name <br /> Owner's Name Address Phone <br /> Contractor's Nam License No. 171,17 1. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ p� <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER EJ (J`J <br /> DISTANCE TO NEAREST: SEPTIC TANK rte_. SEWER LINES -- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION r— AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J_Industrial Open p -,;-_Q,Manteca Dia, of We1%Excavat.ion - _ _ _ <br /> U Domestic/Private E]Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Public Lj Other Delta <br /> LJ <br /> Irrigation Type of Casing <br /> ,Approx. E) Eastern <br /> []Cathodic Protection Depth Specifications <br /> 1-1 i <br /> Geophysical "° Depth of Grout Seal <br /> LJ Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work DoneE]'-- Type df'Pump "H;P, - ?r" 'State Work Done', ti j( <br /> Well Destruction Well Diameter Sealing Material (top 501) r� <br /> Depth Filler MaterialBel <br /> ow 50' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAI,R/ADDITION Lj (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence - 7 Commercial '0 -'Other available within 200 feet.) <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: iW" <br /> Water table depth <br /> SEPTIC TANK Cj Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. E] Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM o Distance to nearest: Well'.; FoundationProperty Line <br /> DESTRUCTION <br /> LEACHING LINE ❑ No. & Length of lines -._Total length/size ` <br /> FILTER 8ED0 Distance to nearest: Well Foundation Property Live <br /> SEEPAGE PITS C] Depth' Siz,eA Number <br /> SUMPS jJ 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'withSan 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' <br /> to become subject to workman§ compensation"laws.of_ California." <br /> Contractor's hiring:or sub-contracting signature certifie's the following: "I.certify that in the performance of the work-for.which .�t <br /> this permit is issued, I shall employ persons subject to workmah's compensation laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed XTitle: �� ® Date: 1,2- -� <br /> FOR DEPARTMENT USE ONLY <br /> Application_Accepted.by AreaStk 466-6781- <br /> Additional Comments: <br /> Lodi 369-3621 <br /> Pit or Grout Inspection Date L� Manteca 823-7104 <br /> Final Inspection by Date � Tracy 835..6385 <br /> Applicant - Return all copies t : Environmental Health Permit/Services 160 F. zelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 5-- Ia ►�{ B3 3 13�d. r <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />