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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �y L1j <br /> Telephone (209) 466-6781 DATE ISSUED k-3 <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. <br /> 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. U- <br /> � <br /> Job Address _ 2E-1AGC• Subdivision Name <br /> Owner's Name // ('i! jl; lO Address 7V fC` Sf ,/�/ Phone <br /> Contractor's Name — License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER Lj <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 'DISPOSAL FLO. PROF. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I f Industrial U Open Bottom [] Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia, of Well Casing <br /> Public [j other Delta <br /> Type of Casing <br /> F] Irrigation Approx. ❑ Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical <br /> Type of Grout <br /> U Other <br /> Surface Seal Installed by <br /> Repair Work Done El Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') Y.l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION j� (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: l Number of bedrooms 3 Lot size .x-2 y o <br /> Character of soil to a depth of 3 feet: 44401*' Water table depth l <br /> SEPTIC TANK Type/Mfg Vao - Capacity No, Compartments 2 <br /> PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal Ib <br /> SEWAGE SYSTEM r, Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION L� <br /> LEACHING LINE No. & Length of lines 3 JO Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS 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 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 workman 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 persons subject to workman's compensation laws of California." <br /> Theapp1 , must cal for all r aired inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: y <br /> F DEPA MENT USE ONLY <br /> Applicat- n Accepted by Area 3 Stk 466-6781 <br /> Additional Comments: [] Lodi 369-3621 <br /> Pit or Grout Inspection by Date 1 / Mantec 823-71D4 <br /> Final Inspection by Date L7 Tracy 835-6385 <br /> Applicant - Return all copies Kvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY {� DATE PERMIT Nr0.. <br /> [NFO <br /> EH 14-26 REV. 10/82 Oat f v 11j nl �� IO182 500 <br />