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APPLICATION .FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT w � <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PER <br /> N0. <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. <br /> Job Address a �.• ��11 <br /> 1Subdivision Name Owner's Name Address`Zi .ice 7.:� 0n�p]��.�Z�Z�71 . <br /> Contractor's Name License No. ` _i�i� Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> "PUMP INSTALLATION Q SYSTEM REPAIR OTHER IJ <br /> " " DISPOSAL FLO. . PROP LINE <br /> DiSTANCE'70 NEAREST hSEPTIC TANK�.,w. •�� SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TY?E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F-1 Industrial U Open Bottom ❑Manteca Dia. of Well Excavation v� <br /> U Domestic/Private EJ Gravel Pack F-1 Tracy Dia. of Well Casing <br /> j ID Public G Other []Delta Type of Casing <br /> i D irrigation Approx. ❑ Eastern Specifications } <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> 17 Geophysical a Type of Grout <br /> LD Other Surface Seal Installed by <br /> Repair Work Done [} Type of Pump H.P. State Wdrk Done <br /> Well Destruction U Well Diameter Sealing Material (top 50`) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/,ADDITION (No­septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence X Commercial _ Other _ <br /> Number of living units: /,_ Number of bedrooms -.2511- Lot size <br /> Character of soil to a depth of 3 feet: �r � - <br /> Water table depth <br /> SEPTIC TANK Type/Mfg` Capacity No. Compartments <br /> Capacity Method of Disposal <br /> • PKC. TREATMENT PLT. � Type/Mfg ,.- <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION J <br /> LEACHING LINE � No. & length of lines rl!S Total length/size� <br /> FILTER BED Distance to.nearest: Well _ Foundation - Property Line _ A <br /> SEEPAGE PITS Depth �� --- Size (p Number <br /> SUMPS U Distance to nearest: Well Foundation_ Property Line _�Q <br /> DISPOSAL PONDS CI <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 certifies the fallowing: "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 signatur certifies the followin : "I certify that in the performance of the work;.for which <br /> this permit i 'ssued, I shall employ persons bject to workman's ensation laws of California." <br /> 4 The applic 11 fo 1 requ' d i p ction Complete aw' g on or Ia side, `� <br /> Signed <br /> itle: Date: <br /> FO DEPARTMENT USE ONLY St 466-6781 <br /> Application Accepted b Area <br /> Lodi 369-3621 <br /> Additional Comments: <br /> Pit or Grout Inspect"on <br /> Date � Manteca 823-7104 " <br /> Final Inspection by <br /> Date Tracy 835-6385 <br /> Applicant - Return all co a to Environmental ea Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 952D1 <br /> FEE BASE MOUNT DUE AMOUNT REMITTED RECEIVED BY DATE'Q PERMIT NO. <br /> ` INFO <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />