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APPLICATION FOR'PERMIT a', <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, 'CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES I 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 2. _7dJ_WJ,_jj1E. rN Subdivision Name <br /> Owner's Name (ti I-� I lC Address 14 Z 4 4v-7 a)-e^iii P-e' 4—e 4' Phone 4f <br /> Contractor's Name 1 License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL.,REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION =E AGRICULTURE WELL-- OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA" CONSTRUCTION SPECIFICATIONS <br /> Industrial Open,Bottom -❑°Manteca T Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ` "� Dia. of Well Casing <br /> v <br /> (7 Public ❑Other, ❑ Delta Type of Casing <br /> C1 Irrigation Approx. ❑ Eastern ' <br /> ❑ Cathodic Protection <br /> Depth Specifications -• > <br /> Depth of Grout Seal �. <br /> Geophysical Type of Grout <br /> ❑Other Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well DiameterA Sealing Material (top 50') <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION'S REPAIR/ADDITION CJ_ (No septic tank or seepage pit permitted if public sewer is <br /> III available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other <br /> Number of living units: Number of bedr oms � Lot size .1 f ', <br /> Character of soil to a depth of 3 feet: ,&1, Water table depth <br /> SEPTIC TANK E Type/Mfg ___ Capacity 110 n No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg''- `"° si b � J Capacity Method.of Disposal <br /> "Distance to nearest: We .�� Foundation `IU Property Line <br /> LEACHING LINE ❑ No. & Length of lines ` Total lerlgth/size <br /> FILTER BED Distance to nearest: Well Foundation ove'r1a Property Line <br /> -SEEPAGE PITS [] Depth ' Size Number. <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ f <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 become­subjectkto 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 /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X ;f Title: "' w Date: <br /> FOR DEPARTMENT USE ONLY �7 <br /> Application Accepted by � / �^-� ' _� Area 13 ❑ Stk 466-6781 <br /> f - <br /> Additional Comments: ! ❑ Lodi 369-362.1 <br /> Pit or Grout Inspection by ! Date Manteca 823-7104 <br /> Final Inspection by F Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: +Environmental 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 NO. <br /> INFO <br /> ' r <br /> EH 13-24 -REV 1 /82 10/82 500 ;. <br /> 14-26 Y <br />