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APPLICATION FOR PERMIT <br /> SAN JCAQUIN LOCAL HEALTH DISTRICT <br /> 1501 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO, O p <br /> 3 ,5,3 2� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE=ISSUED �j 5 <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 Regulation]sof the San Joaquin L cal health District. <br /> AJob Address CT �N - <br /> Subdivision Name <br /> Owner's Name Address !1 Phone / <br /> Contractor's Name License No. ag 7,Z 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 FLA. PROP. LINE } <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS rrVi <br /> INTENDED USE TYPE OF WELL PR03LEM AREA CONSTRUCTION SPECIFICATIONS 0i <br /> IJ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private Gravel Pack Tracy Dia, ofWell Casing <br /> Public �j Other Delta <br /> V <br /> irrigation Type of C <br /> Approx. Eastern <br /> asing S g [� <br /> [ Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> ❑Other Type of Grout <br /> Surface Seal Installed by M <br /> Repair Work Done Type of Pump H.P ^- State Work Done p <br /> Well Destruction Lf Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') er � <br /> f or <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is J } <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial Other <br /> Number of living units: Number of bedrooms �_ Lot size <br /> Character of soil to a depth of 3 feet: Water table depth oy <br /> SEPTIC TANK Type/Mf <br /> 9 Capacity Jf��(� _ No. Compartments '� Y <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well ___ Foundation 8 l Property Line <br /> DESTRUCTION ❑ <br /> LEACHING LINE . ' No. & Length of lines (J Total-.length/size <br /> FILTER BED Distance to nearest: Well Foundation - Property Line 6 [) <br /> SEEPAGE PITS Depth Size 3 Number <br /> SUMPS L-1 Distance to nearest: Well �"`�j} 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 shalemplo persons subject to worknan's compensation laws,of California." <br /> The appli t st 1 for 1 e ired inspections. Complete drawing or reverse side. <br /> Signed Title: Date: <br /> - f FOR DEPRRTMENT'USE ONLY <br /> Application Accepted by "� Area Stk 466-6781 <br /> Additional Comments: �X Lodi 369-3621 <br /> Pit or Grout Inspection b #rn.en <br /> L Date ✓`~Manteca 823-7104 <br /> Final Inspection by /�2 Date L7 Tracy 835-6385 <br /> Applicant - Return all copie to: Etal Health Per 1601 E. Hazelton Ave., A.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> !s X3 -53 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />