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i <br /> APPLICATION FDR PERMIT <br /> ." -, <br /> SRN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, <br /> Telephone (209)456-6781 DATE ISSUED <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1. <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 /> e with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> described, This application is made in complianc <br /> and the Rules and Regulations f the San J aqui n Local Health District. . <br /> Job Address q, Subdivision Name <br /> Owner's Name <br /> ddress /�4 <br /> ?hone <br />€ , i cense Na. Phone �(y�`�L <br /> Contractor's Kam " <br /> a' <br /> i I DESTRUCTION �.! <br /> TYPE OF WELL/PUMP WORK: �� NE4! WELL ❑ WELL REPLACEMENT � ❑ k <br /> F PUMP INSTALLATION �] SYSTEM REPAIR OTHER U rr <br /> SEWER LINES DISPOSAL FLD, PROP_ LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER_ <br /> AGRICULTURE WELL OTHER WELD PITS/SUMPS <br /> FOUNDATION _. <br /> r <br /> INTENDED USE is TYPE OF WELL PROBLEM AREA.. _ GDNSTRUCThON SPEC+IF.ICATi0N5 - <br /> _ — 0_ Diar-of Well -Excavation -" <br /> U Domestic/Private F_� Gravel Pack Tracy Dia. of Well Casing <br /> Public I, �J Other Del ita Type of Casing i <br /> V Irrigation Approx. []Eastern Specifications <br /> Depth Cathodic Protection DepII `1". Depth of Grout Seal <br /> Geophysical '= Type of Grout <br /> r Other Surface Seal 'fed-by <br /> Instal <br /> j <br /> Repair Work Done ❑ Type H.P. ^ `� State Work Done: <br /> e of Pump i . - —,- -+ - <br /> Sealing Materiall(top•50') r n <br /> Well Destruction F-1WellDiameter <br /> Depth Filler Material (Below 5(') if-" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage P'availableewithinu200c �s <br /> feet.)sewer <br /> Installation wi11 serve: Residence e.. Commercial Other ` 41 <br /> Number of b Brooms Lot size �_ � s <br /> Number of living units: �_ 4 + <br /> .__Water table depth d <br /> Character of sail to a°depth of 3 .feet: y �o ��+ "" <br /> Capacity No. Compartments <br /> SEPTIC TANK Type/Mfg Method of Disposal <br /> i . Capacity <br /> PKG. TREATMENT PLT. Type/Mfg r ,x <br /> f '� Foundation Property Line <br /> SE14AGESSYSTEMON ❑ Distance to nearest: Well 0__ da ion <br /> yA X <br /> LEACHING LINE d No. & Length of lines Q Totalxlength/size <br /> 11 i <br /> FILTER BED ED Distance to nearest: Well O Foundations fD*: Property Line <br /> SEEPAGE PITS Depth Size <br /> /Q\ Property <br /> SUMPS � Distance tv nearest: Well � Foundation D� ; Line <br /> t DISPOSAL PONDS ❑�� t = # ' <br /> San Joaquin county <br /> I hereby certify that I have prepared this application and~that the work will be done ihsaccordance with <br /> ordinances, state laws„and rules and regulations of the San Joaquin Local Health District. _ <br /> ance of Home owner or licensed agent's signature cerson1es the in suchmannerto become subjectthat ntohworkmanh compennsatlionwlawsfof California." <br /> permit is issued, I shall not employ any p Y <br /> "I certify that in the performance of the work for which <br /> Contractor's hiring or sub-contracting signature certifies the following: <br /> 's compensation laws of California." <br /> this permit is issued, 'I shall employ persons subject to workman <br /> The applicant ust call r a 1 required inspections. Complete drawing ogHrrse side. pate: " q <br /> ' Signed X Title: <br /> FOR DE RTMENT USE ONLY Stk 466-6781 <br /> Appli tion Accepted b Area <br /> Lodi 354-3521 <br /> Additional Comments: Manteca 823-7104 <br /> Pit or Grout Inspection by Date <br /> Date tpv <br /> Tracy 835-6385 <br /> Final Inspection byApplicant - Return all copies to:" Environmental Heal Permit/Services 1 O1 E. Hazelton P.O. Box 2049, St k., CR 45201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> PATE PERMIT N0. <br /> INFO <br /> 1 31-7 <br /> u 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 u <br />