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APPLICATION FOR PERMIT <br /> SAN JOAQLi'd LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 5 j <br /> Telephone (204) 46b-5781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED GATE ISSUED 1'--Jq-!R4 <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 the San Joaquin Local Health District, <br /> Job Address I ArA J �h�fi pu <br /> Owner's Name �j moi - _ <br /> �/ M��� Address Phone 3 o <br /> Contractor's Name A,ALicense No. Phone rL4,L2k W T <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION LD SYSTEM REPAIR OTHER <br /> EJ- <br /> DISTANCE TO NEAREST: SEPTIC TANK SV I-�.- SEWER LINESTt DISPOSAL FLO. PROP. LINE a �{ <br /> FOUNDATION AGRICULTURE WELL p _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation - <br /> Domestic/Private <br /> xcavation _Domestic/Private fVGravel Pack Tracy Dia. of Well Casing 6 i� <br /> Public ❑ Other Delta <br /> Irrigation Type of Casing <br /> Li 9 _1ya Depth Eastern Specifications <br /> Cathodic Protection Depth �• <br /> LJ Geophysical <br /> Depth of Grout Seal ` <br /> ❑Other Type of Grout G <br /> Surface Seal Installed by y� <br /> Repair Work Done Type of Pump H.P. State Work Done T <br /> Well Destruction L 1 Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION V <br /> LI ❑ (No septic tank or seepage pit permitted if public sewer is � <br /> — available within 200 feet.) v <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 U 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 C <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 ❑ Depth Size Number <br /> SUMPS LI 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 /> 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 became subject to workman compensation laws of California." <br /> Contractor's hiring or sub-contracting ignature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I sh amp oy ersons subject to workman's compensation laws of California." <br /> The applic us ca fo 11 red inspections. Complete drawing on reverse side. <br /> Signed .12 Title: AJ Date: Z <br /> 0 EPARTMENT US NLY <br /> Application Accepted by rea ❑ Stk 466-6781 <br /> Additional Comments: ❑ Lodi 364-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date j.3D-5 C� L7 Tracy 835-6385 <br /> Applicant - Return- all copies to: En v i ronmen ter eaIth Permit/Services 1601 E. Hazelton Ave. P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 1R g -moi <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />