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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH,DISTRICT; _ .� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA J U L 2 4 j4 g 4 PERMIT N0. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED LOC <br /> IAI <br /> (Complete in Triplicate) ie H-EALTH; DISTRIrri <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 Local Health District. <br /> Job Address C WR W6T Subdivision Name <br /> Owner's Name rill _ Address ,AJ '57 Phone <br /> Contractor's Name �D License No. Phone 4*2- <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ind <br /> ustrial_ ( ._ Open'r8ottom- (]Manteca - -0ia-of-Well Excavationes <br /> j 6omestic/Private ❑Gravel Pack ❑Tracy Dia. of Well Casing <br /> v❑1PP.ublic ❑ Other ❑ Delta Type of Casing <br /> Irrigation :Approx. ❑Eastern Specifications <br /> ❑Cathodic Protection. 'Depth� <br /> E Depth of Grout Seal <br /> ! ❑Geophysical Type of;Grout <br /> ❑ether Surface Seal Installed by <br /> v <br /> Repair Work Done ❑ Type of Pump. H.P.34 SUbR('jJU2�tate Work Done. <br /> Well Destruction ❑ Well Diameter. Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION " REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> EDU (n <br /> 1 available within 200 feet.) v <br /> Installation will serve: Residence _ Commercial _ Other <br /> ` Number of living units: <br /> �" Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest:' Well Foundation Property Line <br /> i' DESTRUCTION :+ <br /> l LEACHING LINE ❑ No. & Length of lines Total length size <br /> I! FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> (­i_---SUMPS— -' ❑ "Distance to-nearAt" We11 "" �F6undation r"r"�" Property Line"^* "A" *r' ' <br /> DISPOSAL PONDS ❑ 9 <br /> I hereby certify that I have prepared this application and that the work will'be done in accordance with San Joaquin county <br /> f 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 1s 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 Aust call for all require inspections. Complete dr��a�nwting on reve se side. <br /> Signed Title: [Y / Date: <br /> F R DEPARTME USE ONLY _ � Z _d / <br /> I Application Accepted b Aria~ 1}C( Stk 466-6781 <br /> CC❑�� <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 /> P Applicant - Return all copies to;:'' Environmental Health Permit/Services 1601+5E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNTI DUE AMOUNT REMITTED RECEIVED BY DATE J_iFIT N0. <br /> INFO <br /> L EH 13-24 REV. 10/82 <br /> 10/82 500 <br /> 14-26 <br />