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APPLICATION FOR,PERMIT <br /> SAN JCAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> { Telephone (209) 466-6781 PERMIT N0. <br /> G PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> ( 1 (Complete in Triplicate) <br /> k 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 ofzthe San Joaq in Local Health District. <br /> Job Address ' <br /> �� � 't"a!i1� deel! Subdivision Name ' <br /> Owner's Name Address11 _p <br /> Contractor's Name PhoneLicense,No. 32g_4,, Phone <br /> TYPE OF WE WORK: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHERU <br /> E <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL fLD. PROP. LINE <br /> FOUNDATION —N6 RICULTURE WELL <br /> �� e OTHER WELL PITS/SUMPS <br /> INTENDED SE TYPE"OF WELLPROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F-1 Industrial ❑ Open'Bottom E Manteca Dia, of Well Excavation <br /> U Domestic/Private ❑Gravel Pack Trac <br /> ❑ y Dia, of Well Casing <br /> ❑ Public ❑ Other ❑ Delta <br /> L, Irrigation i Type of Casing <br /> Approx. Eastern <br /> ❑ Cathodic Protection Depth Specifications <br /> ❑Geophysical Depth,of Grout Seal <br /> r <br /> Lf Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P'. State Work Done �!J <br /> Well Destruction U Well Diameter, Sealing Material (tap 501) <br /> C ? Depth Filler Material (Below 501) W <br /> TYPE OF SEPTIC WORK: NEWINSTALLATIONAh ITION (No septic tank or seepage pit permitted if public sewer is <br /> Installation will .serve: Residence _ '`Commercial.. E'_—Other ': available within 200 feet.) <br /> Number of living units: ]Number of bedrooms Lot size <br /> Character of soil to a depth of,,3 feet: 5' ell <br /> Water table depth 5"0 p <br /> SEPTIC TANK [J Typ-e/Mfg <br /> Capacity No, Compartments <br /> PKG. TREATMENT PLT. TyP /e Mfi9� <br /> ❑ Ide <br /> r Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance:to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ i , <br /> LEACHING LINE U No"& Length of lines I � Total length/size <br /> FILTER BED ❑ DistanceIto nearest:,�Well Foundation Property Line n <br /> SEEPAGE PITSDeptho� r� Size <br /> Number <br /> SUMPS' C1 Oistance''to nearest: Weil <br /> OISROFoundation jALL- Property Line $ Lf + <br /> L - ❑ )� <br /> . - 111 PONDS <br /> d , <br /> I hereby certify that I have preparred 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 2 <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 applic t must call for i required inspections. Complete drawing on reverse side. <br /> Signed X VT A 0 Title: Date: 4 <br /> DEPAR T USE ONLY <br /> Application Accepted by Area Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection—by—_ Date Tracy 835-6385 <br /> Applicant - Return all copies to: Environme 1 Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i' <br /> FEE BASE j AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, <br /> INFO <br /> I , <br /> �� _0 <br /> EH 13-24 REV. 10/82 <br /> 14-26 - i0/82 500 <br />