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P <br /> k <br /> } <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH OISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CAPERh1IT N0. 3�J D <br /> ' Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> (Complete in Triplicate) <br /> ' Application is hereby made to thefSan--Joaquiri 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 /> r and the Rules and Regulations of the San Joaquin Local Health District. <br /> t <br /> Job Address z e44 <br /> Subdivision Name <br /> Owner's Name11;17 <br /> c ! / Address Phone �p <br /> I Contractor's Nam6 a4 - License Na. Phone -S�Q,S`- <br /> TYPE OF WELL/PUMP WORK: NE4! WELL WELL REPLACEMENT ❑ DESTRUCTION <br />+' PUMP INSTALLATION ❑ SYSTEM REPAIR U OTHER <br />� V <br /> DISTANCE TO NEAREST: SEPTIC TANK ! SEWER LINES DISPOSAL FLO. PROP. LINE .. <br /> FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS UZ <br /> INTENDED USE TYPE,OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> k� ❑ Domestic/Private 7 Gravel Pack ❑ Tracy Dia. of Well Casing <br /> I ! <br /> Public '� �j Other El Del to <br /> Type of Casing <br /> V Irrigation Approx. Eastern <br /> E Cathodic Protection IDepth Specifications <br /> y Depth of Grout Seal <br /> L]Geophysical <br /> LJ Other Type of Grout f r. <br /> iSurface Seal Installed by v 1 <br /> Repair Work. Done ❑ Type of Pump H.P. State Work Done D <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is. <br /> available within 200 feet.) <br /> Installation will serve: Residence _Commercial _ Other <br /> Number of living units:Number ojbe ooms l Lot size <br /> Character of soil to a depth of 3 feet: - Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg (f Capacity Method of Disposal ' <br /> SEWAGE SYSTEMDistance�to nearest: Well x Foundation Property Line s r <br /> DESTRUCTION ,. <br /> i <br /> LEACHING LINE U No. & Length of lines X Total length/size I <br /> FILTER BED Distance'to nearest: Well Foundation Property Line <br /> ' I <br /> SEEPAGE PITS" =Depth 'Size, o Number <br /> ;(SUMPS �) distance tp nearesS:_ Well Foundation �Q r Property Line L5 <br /> DISPOSAL PONDS <br /> f, <br /> I hereby certifythat Thave prepared this applicat:ion�d'1Hat 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 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 workman5 compensation laws of California." s <br /> Contractor's hiring or sub-contracting signature certi.fi.es''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 applicanta-cal-1-1-f a1 required inspectiorist Complete drawing onrse side. <br /> Signed X i. %Title: r Date:FOR DEPARTMENT USE ONLY <br /> Applicccepted by Area Stk 466-6781 <br /> Additional Comments: adi 369-3621 <br /> Pit or Grout Inspection b Date Manteca 823-7104 <br /> Final Inspection by r Date L Tracy 835-6385 <br /> � s <br /> __Appl.icant_._ Return all>,cop es. o_:- Environmental Hea4th Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED w RECEIVED BY .DATE. PERMIT NO. <br /> INFO '(0� { �q <br /> IO3�,.s.(J ' - 1 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />