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r � <br /> • V <br /> APPLICATION FOR PERMIT <br /> SAN JCAQLit: LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> -�IiC/- (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 an egulayiors of the San Joaquin Local Health District. <br /> Job Address I �iore <br /> Owner's Name dPAddress Phone <br /> Contractor's Name License No, Phone <br /> TYPE OOF^+WELL/PUMP WORK:, NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> � J PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER <br /> 0[5TA ETD EA S7IC�7pl � N S L DISPEOS�L LLD. PROS/SUMPS "I <br /> FOUNDATION r�� <br /> ¢FFf � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I strial pen Bottom �] Manteca Dia, of Well Excavation <br /> stic/Private Gravel Pack ❑ Tracy Dia, of Well Casing <br /> Public ❑Other ❑ Delta <br /> Type of Casing <br /> Lf Irrigation Approx. Eastern <br /> Depth <br /> th specifications (� <br /> Cathodic Protection p �+ <br /> Geophysical Depth of Grout Seal <br /> ❑ <br /> LJ Other ' Type of Grout <br /> Surface.Seal"�talied by <br /> Repair Work Done ❑ Type of Pump H.P. A` tate Work Done <br /> Well Destruction L Well Diameter Sealing-Material (top 50') <br /> Depth 'Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSJAL-:AYICN Ll REPAIR/ADDITION D (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 oflri4ing units: Number of bedrooms Lot size } , <br /> Character of soil to a depth of 3 feet: Water table.depth--- 'r�—� <br /> f <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. L] Type/Mfg Capacity . .may F• "Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line ,. <br /> t' <br /> DESTRUCTION ❑ - <br /> LEACHING LINE ❑ No. & Length of lines �'� Total length/size <br /> •FILTER BED Distance to nearest:,.Well Foundation Property Line l <br /> SEEPAGE-PITS ❑ Depth � Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> D.ISPOSAL-PONDS ❑ `} <br /> y Thereby certify that I have pr pared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances,, state laws, and riles and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed.6gent`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 ' ed, I shaZ,, y persons subject to workman's compensation Taws of California•" <br /> The appltrctallor ir d insKtions, Complete drayifj�g on re rse side. <br /> f <br /> IL <br /> Signed x w Title: cif/ Date: <br /> D PA MENT USE ONLY F <br /> Ap is ion Accepted by Area - I 'S�-0. Stk 466-6781 ` <br /> Additional Comments: odi 369-3621 <br /> Pit or JrojA Inspection by Date �r,�� Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies t : Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2004, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE' AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> EH 13-24 REV, 10/82 10/82 500 <br /> 14-26 <br />