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r - 4 <br /> APPLICATION FOR PERMIT �- <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. -S <br /> i Telephone (209) 466-6781 <br /> I DATE ISSUED <br /> t PERMIT EXPIRES I YEAR FROM DATE ISSUED _ <br /> (Complete ir,Triplicate) <br /> Application is hereby made to thejSan 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 Heal District, <br /> Job Address , ubdivision Name r� <br /> f Owner's Name Address 7 honeS <br /> Contractor's Name z License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> e PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONii AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom []Manteca Dia. of Well Excavation i+ <br /> Domestic/Private Gravel Pack Tracy Dia. of Wel] Casing <br /> Public Other - Del to Type of Lasing <br /> �jIrrigation Approx. Eastern Specifications ' y <br /> Cathodic Protection Depth <br /> - Depttl-of Grout Seal <br /> Geophysical Type of Grout G <br /> U Other Surface Seal Installed by (� <br /> F "1 <br /> I Repair Work Dane FJ "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 RK: NEW INSTALLATION F_ REPAIR/ADDITION D (No septic tank or seepage pit permitted if public sewer is <br /> . - . � �-. available within 200 feet.) <br /> Installation will serve: Resi�dente'�_ Commercials- . , 0therYYlA-pYo�,tc <br /> Number of living units: / Number of bedrooms Z' Lot.size _ <br /> € Character of soil to a depth of 3 feet: "g Water table depth p <br /> ' SEPTIC TANK LK Type/Mfg f Capacity 7 m d No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of'Di sposal <br /> SEWAGE SYSTEM I—� Distance to nearest: Well Foundation f O Property Line ,_ <br /> I DESTRUCTION <br /> LEACHING LINE Y U No. & Length of lines 4 m Total length/size 51c, <br /> r <br /> FILTER BED Distance to nearest: Well Foundation L D J ' Property Line <br /> SEEPAGE PITS Dyi . Depth it 2. S_ ! Size 3-13 �� Number <br /> SUMPS �� Distance to nearest: 4Weil Foundation f,n �� Property Line <br /> DISPOSAL PONDS ; <br /> �k s <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, 1 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 applic t must call f all required inspections. Complete drawing on reverse side. �� <br /> Signed X -r --Title: Date: 44- -- ^ 41 <br /> FOR O PARK NT USE ONtI' <br /> Application Accepted by _ Area —d . Stk 466-6781 <br /> Additional Comments: ' Lodi . 369-3621 <br /> or Grout Inspection..by.' Date Manteca $23-7104 <br /> " Date ❑ Tracy 535-6385 <br /> Final! lnspection.by <br /> Applicant -.Return all copies to: Environmental He lth ermit/Services 1601 E. Hazelton"Rve., P.O. Box 2009, Stk., A 95201 <br /> FEE BASE AMOUNT' DUE AMOUNT REMITTED RECEIVED BY DATE µ EPERMITfO.'INFO10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />