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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3 a <br /> Telephone (209) 466-6781 DATE ISSUED <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 00 <br /> and the Rules and Regulations of the San Joaquin Local Health District, ry / +J.1 <br /> Job Address Subdivision Name + +d! <br /> Ire Address Phone -� <br /> Owner's Name — �° Phone <br /> Contractor's Name License No. <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR 1__� OTHER U <br /> SEWER LINES DISPOSAL PLO. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t Industrial U Open Bottom F-I Manteca Dia. of Well Excavation <br /> U Domestic/Private []Gravel Pack ❑Tracy Dia. of Well Casing <br /> Public �j Other 1:1 Delta Type of Casing <br /> LjIrrigation Approx. E]Eastern Specifications <br /> ❑Cathodic Protection Depth Depth of Grout Seal <br /> Geophysical Type of Grout <br /> LJ Other Surface•Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ We11 Diameter Sealing Material (top 50') N, <br /> Depth Filler Material (Below 50') <br /> sewe <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IJ REPAIR/ADDITION ` (No septic tank or seepage pit <br /> availableewithin if u?00cfeet.) is <br /> Installation will serve: Residence _ Commercial f Other "M a ! G >ua e, �art_- <br /> Number of living units: 37— Number of bedrooms Lot size I <br /> Water table depth <br /> Character of soil to a depth of 3 feet: ��� <br /> d <br /> T e Capacity No. Compartments <br /> SEPTIC TANK CJ yP /Mf g Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity <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 DED Distance to nearest: Well Foundation Property Line <br /> 2 <br /> SEEPAGE PITS {� Depth Size Number <br /> f <br /> f Foundation _�- Property Line <br /> SUMPS �� Distance to nearest: Well+ <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 /> ies the following: "I certify that in the per <br /> Home owner or licensed agent's signature certifof 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 far which <br /> this permit is issued, shall employ persons subject to workman's compensation laws of California." <br /> The a Lica ust 1 required inspections. Complete drawing on reverse side. <br /> Date: <br /> Signed X Title: <br /> R DEPARTMENT USE ONLY <br /> Area 5tk 466-6781 <br /> Application Accepted by Lodi 369-3621 <br /> Additional Comments: Manteca 823-7104 <br /> Pit or Grout Inspection b Date <br /> + Date' � Tracy 835-6385 <br /> Final Inspection by <br /> Applicant - Return all copies o: Env men al "It <br /> I th Permit/Services 160 Wazelto, Ave., P.O. Box 2009, Stk., CA 952 <br /> rFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> DATE PERMIT NO. <br /> INFD <br /> 10182 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 t3 7 <br />