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APPLICATION FOR PER"SIT <br /> SAN JOAQ�iN LOCA_ HEALTH D;STRIC yy `gS� p --7 <br /> 1601 E. HAZELTON AVE., STOCKTON, � J� PERMIT NO. O r ` <br /> Telephone (209) 466-6781- Y, � LOC&E ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED !SAN 10''Q ;S TR;ri I <br /> (Complete in Triplicate) <br /> n���� <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 /> Jab Address--Q-19 5� t ` � Subdivision Name <br /> 1 Q Address d f�.t Phone <br /> Owner's Name <br /> License No. <br /> Contractor's Name <br /> j.J / Phone i <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION `A 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 /> Industrial ❑ open Bottom ❑Manteca Dia. of Well Excavation <br /> Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing I <br /> Delta ! <br /> ❑ <br /> Public ❑other ❑ Type of Casing <br /> 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 Tey <br /> Repair Work Done [D Type of Pump H.P. State Work Done a fu 75.1 1 S <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') — (� <br /> Depth Filler Material (Below 50') �J + <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION F-1 REPAIR/ADDITION _j (No septic tank or seepage p�availableewithiif nu20Ocfeet.)sewe �'S <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: <br /> Water table depth <br /> h Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Type/Mfg <br /> Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ depth Size Number <br /> SUMPS U <br /> Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> "I certify tha <br /> Home owner or licensed agent's signature certifies the following: t 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 <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applican st call for re u ed inspections. Complete dra g on reverse side. Date: <br /> Signed X Title: <br /> F ARTMENT USE ONLY ❑ Stk 466-6781 <br /> Application Accepted by Area <br /> ❑ Lodi 369-3621 <br /> Additional Comments: arteca 823-7104 <br /> Pit or Grout Inspection by Date J� <br /> Final Inspection by <br /> Date ' �I ❑ Tracy 835-6385 <br /> mental alth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant - Return all copies to: Environ <br /> L140 <br /> AMOUNT DUE AMOUNT REMITTED RECEIVED 8YDATE PERMIT NO. <br /> ift �vYl ��4 <br /> �'�J I <br /> �4 1 10/82 500 <br /> EH 1REV. 10/82 <br /> 4-2b �� �� <br />