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APPLICATION FOR'PERMIT <br /> SAN JOAQUIN 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 /> ! (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 andAegulA .1ons'of the San Jo yy in Lo al Health District. <br /> Job Address Q Subdivision Name n/ _ � <br /> Owner's Name �L Address Phone <br /> Contractor's Name ."-fL License No. Phone <br /> Wz <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> ' S <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ p` <br /> DISTANCE TO NEAREST: SEPTIC TANK ,J --rv. _ SEWER LINES DISPOSAL FLU. PROP. LINE C� <br /> . — k - t <br /> FOUNDATION 'AGRICULTURE WELL OTHER WELL PITS/SUMPS `, <br /> INTENDED 115E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CIN <br /> n <br /> F I Id-- rial,-. T --- �_ -_ <br /> .a.-.,,,,...i. <br /> �� Open' Bottom �[] Manteca Dia. of Well Excavation <br /> Lj <br /> Do <br /> 4stic/Private [ Gravel Pack ❑ Tracy- Dia,-of Well_Casin <br /> grt <br /> Publfic Cj Other Delta -- + <br /> }. ` Type of Casing . 4 <br /> Lj Irrigation <br /> Approx, Ej Eastern",, ,,.., <br /> t Cathodic Protection Depth � L Speci"ficdtions 7. ""s <br /> ❑Geophysical Depth of.Grout Seal ; <br /> ❑Other i Type of Grout 4 $ <br /> 4 Surface Seal Installed <br /> by- <br /> Repair <br /> y <br /> Repair Work Done ❑ Type of"Pump i H.P. - Skate Work Done <br /> Well Destruction Well Diame erg Sealing Material (tgp.50')t3 <br /> 1 # Depth Filler Material (Below 50'} <br /> 1 r <br /> " 'TYPE 0 "SEPTIC'WORK: NEW INSTALLATION REPAIR/AODI-TION"-ff-l�(No�septIc-tank-or seepage i "permitted if` public sewer-is- &i ---- <br /> + available within 200 feet,) <br /> Insta+llation will serve: Residence L Commercial 0 er <br /> r <br /> Number of living units: ` _ ,`` —AC,— j r <br /> � Number of bedrooms~ Liie <br /> —ot sj <br /> Character of soil to a depth of 3 feet: Water table depth" <br /> SEPTIC`TANK Type/Mfg Capacity - _ -No- Compartmerfts:� <br /> j.. PKG. TREATMENT PLT. T e \" <br /> 0 Yp Mf/: 9 . �. �1 4`•:Gapacity Method of Disposal <br /> SEWAGE SYSTEM <br /> Distance to nearest: Well Foundation Property L-ine <br /> DESTRUCTION t• ❑ ( <br /> f LEACHING LINE No. & Length of lines Total length/size_ OtJ <br /> II FILTER .BED Distance to nearest: Well Fopndation property Line r� <br />{ <br /> 1 SEEPAGE PITS Depth Size Number ( ':, <br /> SUMPS . U Distance to nearest: Well FoundationPperty Line <br /> DISPOSAL PONDS ` . r <br /> j I hereby certifylthat 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-r_egu.l.a.t.ions_of.the San-JoaquinYL--gcal-Heath-•District, r <br /> Home owner or licensed agent',s signature certifies the following: "I certify that in the perforinance of the work for which this <br /> permit :is issued;tI shall not employ any person in such manner as to become subject to work`man� compensation laws of California." <br /> Contractor s hiring or sub-contracting signature certifies the fo1-1owingf±":Icertify that in the performance of the 4rk for which <br /> s c <br /> this permit is issued, I shall employ persons subject to workman' ompensation laws of California." <br /> The applicant must call or.411requ' inspections. Complete drawing on reverse side. i <br /> Signed X o I Title: 1 Date: <br /> FOR.APARTMENT,USE.ONLY <br /> Application Accepted by i Area Stk 466-6781 t <br /> Additional Comments: ` <br /> _ Lodi 364-3621 <br /> Pit or Grout-Inspection r. I" Date ❑ Manteca 823-7104 , <br /> Final Inspection by s Date rs ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Enviro tal Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., (A 95201 <br /> FEE BASE AMOUNT DUE GAMOUNT REMITTED . RECEIVED BY DATE PERMIT NO. i r <br /> INFO 7 <br /> _. .EH 13x :,24- REV. 1O/82 .s3 �°_ 1OJ82-50D"" - <br />