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.__......... . <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH :DISTRICT <br /> 1601 E. HAZELTON AVE_ STOCKTON, CA PERMIT N0. <br /> Telephone (209) 465-6781 s <br /> DATE ISSUED <br /> PERMIT EXPIRES I YEAR FROM DATE.ISSUED <br /> (Complete in Triplicate) <br /> i <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 Lo al Health District. <br /> Job Address 1.26 . Subdivision Name �L' <br /> Owner's Name Q!'p dl/ Address ����' n/ J�/l.�?• Phone f- W/g <br /> i <br /> Contractor's Name License No. 3_A?Q — Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ 1 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TY?f OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public F-1 Other Delta <br /> Type of Casing <br /> - — } I.rrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical <br /> Type of Grout <br /> LJ Other <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION KI REPAIR/,ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other t <br /> Number of living units: —I— Number of bedrooms ,z Lot size r <br /> Character of soil to a depth of 3 feet: Water table depth r <br /> SEPTIC TANK Type/Mfg Capacity /.?DO No. Compartments <br /> PKG, TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ` <br /> LEACHING CINE U No. & Length of lines Total length size -� <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS [Ij Depth o7S Size yt � Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL-PONOS <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 workmant 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 11 for all re uired inspections. Complete dr 'ng on reverse side. _ > <br /> Signed X Title: Date: <br /> R QE ARTMENT USE ONLY Stk 466-6781 <br /> pplication Accepted,by Area IV <br /> Add1ional1Comments: Lodi 369-3621 <br /> Pit or IG rout Inspection Date U Manteca 823-7104 ; <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant -'Return all copi o:, nvironmental 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 /> f <br /> EH 13-24 REV. 10/82 C�j /��a 10/82 500 <br /> 14-26 i%Z <br />