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APPLICATION FOR PERM11 <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STCCKTON, CA <br /> Telephone (209) 466-6781 PERMIT NO. k _ <br /> % f PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED�y- <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joeq'uin 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`Loc i Health Distr.ict., <br /> Jab Address Subdivis' n Name <br /> Owner's Name <br /> r s Phone <br /> Contractor's Name ease No. <br /> PhoneQ_ <br /> TYPE OF WELL/PUMP WORK: NEW WELL �W L REPLACEMENT <br /> t---�� DESTRUCTION U Y <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESL` <br /> .. -T DISPOSAL FLD. PROP. - N <br /> FOUNDATION AGRICULTURE WELL - ' . - <br /> OTHSER.WELL PITS/5UMPS <br /> INTENDED USE .- .—_ _ <br /> ------.,, TYPE F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I Indtrial =__ �x� <br /> pen Sottom Manteca a---atio <br /> , f Well Excavn <br /> omestic/Private .,Gravel oPack Trac ii <br /> � y pia. of Well Casing <br /> Public <br /> ❑Other ❑ Delta <br /> Lj Irrigation Approx. [] Eastern Type of Casing <br /> [Cathodic Protection Depth specifications l)J <br /> ❑Geophysical s Depth of Grout Seal y <br /> LJ Other# .. Type of Grout ti r <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pum �+ <br /> r'�. ❑ yP P H.P. State Wor Done <br /> Well Destruction FIJ.'Well Diameter Sealing Material {top 50'} , <br /> r <br /> Depth . r Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/•ADDITION (No septic tank or see a e it 7 <br /> p p g p permitted if public sewer is 7 <br /> Installation will serve: Residence _ Commercial _ Other available within 200 feet.) rp <br /> Number of".1 iving units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3,feet: xr- <br /> Water table depth y-, <br /> SEPTIC TANK E] Type/Mfg Capacity y[ <br /> p y No. Compartments <br /> PKG. TREATMENT PLT, Type/Mfg 1 Capacity Method of Disposal <br /> DESTRUCTION <br /> SEWAGE SYSTEM Distanceito nearest: Well Foundation Property Line <br /> _ ❑ <br /> LEACHING LINE ❑ ,No. & Length of lines Total length/size ` <br /> FILTER-BED Distance to nearest: Well Foundation Property Line ' <br /> SEEPAGE PITS Depth <br /> ----_ — �-. Size Number <br /> SUMPS <br /> ❑l 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 laws, and rules and regulations of the San Joaquin Local health District. <br /> Home owner_ or licensed agent's signature certifie-S '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's 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 . sons subject to workman's compensation laws of California." <br /> The applicant mus al far all req i d ins ei't;ons. Complete dr g o everse..Side. <br /> Signed X Title: Date: <br /> DEPRRTM NT USE NL T v <br /> Rppl d o Accepted by Area - :7 Stk 466-6781 <br /> Addi Tonal Comments T . ba <br /> Lodi 369-3621 <br /> Pit or G� Inspection by Date y LJ Manteca 823-7104 <br /> Final Inspection by Date <br /> x Z- 2_ - L Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental 4e.alth Permit/Services 1601 E. Hazelton P.O. Box 2009'- Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE _� PERMIT N0. <br /> INFO s 1 <br /> EH 13-24 REV... 10/82 <br /> 14-26 .-s 10/82 500 <br />