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e <br /> APPLICATION FOR PERMIT <br /> SAN JCAQUiN LOCAL HEALTH DISTRICT PERMIT N0. `Y3 r /�f0 1r <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <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 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 Joaquin Local Health District. 6 <br /> Job Address / �- r �h , —` �14e 1 <br /> Owner's Name AddrePhone <br /> ss ;. rYi- . 6 <br /> JJ Phone <br /> Contractor's Name .q �J License No. ^A <br /> TYPE OF WELL/PUMP WORK: NEL! WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTA�LLATION ❑ SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES DISPOSAL LLD_f � PROP. LINE <br /> J --� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Y ❑'Industrial ❑ Open Bottom ❑Manteca =Dia. of'Well Excavation f' <br /> J15G Domestic/Private ❑ GravelePack ❑Tracy `.� Dia. of Well Casing <br /> ` <br /> ❑ Public ❑ Other ❑DeltaType of Casing <br /> Irrigation Approx. ❑ Eastern Specifications <br /> Depth .:Y :-...: «..4: <br /> ❑Cathodic Protection Depth of Grout-Seal <br /> ❑Geophysical -Type of Grout <br /> Other � �-}1- Surface Seal Installed by 11 <br /> Repair Work Done Type of Pump �{�( H.P. � 1 1 State Work Dane <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') — <br /> } Depth + Filler Material (Below 5C') <br /> ( TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION LJ <br /> septic tank or seepage pit <br /> avaelableewi,thinu2O0cfeete) is <br /> Q <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of,living units: Number,of bedrooms Lot size <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> ❑ Capacity No. Compartments <br /> SEPTIC TANK Type/Mfg <br /> Capacity <br /> PKG. TREATMENT PLT. ❑ Type/Mfg - y Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> C] <br /> DESTRUCTION <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation +1 Property Line <br /> SEEPAGE PITS ❑ Depths Size Number <br /> Property Line <br /> SUMPS ❑ Distance to nearest: Well Foundations <br /> DISPOSAL PONDS ❑ <br /> } <br /> I hereby certify that I have prepared6this appl'i'cation and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules andlregulations 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 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 emplo rsons subject to workman's compensation laws of California." <br /> i <br /> The abl, ant m t call 11Rre ire�Rp <br /> ctians. Complete drawing on reverse side. _L- <br /> r Title: <br /> Date: <br /> Signe <br /> EPARTMENT USE ONLY ❑ Stk 466-6781 <br /> Application Accepted by ; Area � <br /> =1 Lodi 369-3621 <br /> i Additional Comments: <br /> Date ❑ Manteca 823-7104 <br /> Pit or Grout Inspection b <br /> r <br /> Date - LD Tracy 835-6385 <br /> r Final Inspection by i* - <br /> 1 <br /> Applicant -.Return all copies o: Enviro me to Health Permit/Services 160 E. Hazelton Ave., P.O. Box 2009, 5t k., CA 95201 • <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, <br /> INFO 3� <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 l 1 k <br />