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t APPLICATION FOR PERMIT <br /> „ r <br /> F SAN JOAQUiN LOCAL HEALTH DISTRICT PERMIT NO. <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 DATE ISSUED 67/Z_7 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein cA <br /> n County Ordinance No. 549 far sewage or No. 1862 for well/pump <br /> described. This application is made in compliance with San Joaqui <br /> and the Rules nd Regulations of the San Joaquin Local Health District, <br /> Job Address FF�TTDT Sub¢ivisi n Name <br /> Address IkJ <br /> Phone <br /> Owner's Name Phone �( <br /> Contractor's Name License No. <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR V OTHER U PROP. LINE <br /> {iJ1� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ID Industrial Open Bottom F-I Manteca <br /> Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public [j Other Delta Type of Casing <br /> L <br /> Approx. Eastern <br /> Irrigation App Specifications <br /> Cathodic Protection Depth Depth of Grout Seal <br /> Geophysical Type of Grout <br /> Other Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') r <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION E� REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence i Commercial _ Other O <br /> Number of living units: Number of bedrooms Lot size <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK Type/Mfg Capacity <br /> Capacity Method of Disposal <br /> PKG. TREATMENT PLT. Type/Mfg Property Line <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation <br /> DESTRUCTION <br /> No. & Length of lines Total length/size <br /> LEACHING LINE U g Property Line <br /> FILTER BED 1--`1 Distance to nearest: Well Foundation <br /> Depth Size Number <br /> SEEPAGE PITS ❑ p Property Line <br /> SUMPS L—� Distance to nearest: Well Foundation <br /> DISPOSAL PONDS �1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> s 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 /> atio <br /> permit is issued, I shall not employ any person in such manner as to become subject to workmanb cc penst in the mance ofwthe fwork tfor nwhich <br /> Contractor's hiring or sub-contrapting ersonsusubjectre ltoeworkman'ss the lccompensationowing: 111 rlaws oftify aCalifornia." <br /> this permit is issued, shall employ p <br /> The applic must 1 for 1 quir ' spe tions. Complete drawi re erse side. Date. <br /> SignedTitle: <br /> • P TMENT US Z Lyi � 0 Stk 466-6781 <br /> ea <br /> Application Accepted by / ❑ Lodi 369-3621 <br /> Additional Comments: Date LL] Manteca 823-7104 <br /> Pit or Grout Inspect' n Tracy 835-6385 <br /> Final Inspection_.by Date <br /> - Return all cop es o <br /> Environmental Health er /Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk <br /> Applicant ., CA 95201 <br /> Environmen <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED <br /> RECEIVED BY DATE PERMIT N0. <br /> INFO s $3 �3 <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />