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APPLICATION FOR PEFiMi T <br /> SAN JOAQI,IN LOCAL HEALTH JiSTRICT g <br /> 1601 E. HAZELTON AVE., STOCKTOh, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> - DATE ISSUED ��b A 3 <br /> PERMIT EXPIRES 1 YEAR FROM 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 and Regulations of he San Joaquin Local Health District. <br /> Job Address ¢ division Name <br /> l� Owner's Name Address P.U-V 3 s� � Phone 4 <br /> Contractor's Name License No. Phone_3.9yl <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOJNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I� Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation <br /> (J Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing <br /> Public Other Delta Type of Casing <br /> V Irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> ❑Geophysical Type of Grout <br /> U Other Surface Seal Installed by c� <br /> Repair Work Done Type of Pump H.P, State Work,Qone <br /> Well Destruction Well Diameter Sealing Material (top 50') <br /> Depth (S0,** Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (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 of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Ej Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. E Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Cj Depth Size Number <br /> SUMPS l—� Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ED <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county O <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 pr1 <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> Thea li'cant s all/f/gr all r �iredn spec ions. CompleteSigne�Appl <br /> p .r��/`' Q Title: Date:MENT USE ONLY ❑ <br /> i Accepted 4bySLL Area Std 466-3621 <br /> Additional Comments: <br /> Lodi 369-3621 <br /> Pit or Grout InspectiDate Manteca 823-7104 <br /> Final Inspection by DateTracy 835-6385 <br /> Applicant - Return all copielth Permit/Services 1601 Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY L PERMIT NO. <br /> INFO <br /> V p, o 3 <br /> 10/s2 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />