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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. '73Z <br /> Telephone (209) 466-6781 �y <br /> - " DATE 15suED `43 <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 <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address '�S /Y subdivision Name <br /> Owner's Name Address JVD J <br /> Contractor's Name License No. 3 Phone <br /> i <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION i <br /> I <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U ) <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial Lf Open Bottom ❑ Manteca Dia. of Well Excavation r <br /> U Domestic/Private F_�Gravel Pack ❑Tracy Dia, of Well Casing CS <br /> Public Other ❑ Delta Type of Casing W <br /> Lj Irrigation Approx. ❑ Eastern Specifications V1 <br /> F—ICathodic Protection Depth <br /> Depth of Grout Seal <br /> L]Geophysical Type of Grout <br /> Other Surface Seal Installed by Z <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> i <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L—! REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is <br /> / available within 200 feet.) <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 �1 <br /> SEPTIC TANK [ Type/Mfg ' Capacity ®O" No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well 6U. Foundation /p� Property Line <br /> DESTRUCTIONZV <br /> T <br /> LEACHING LINE No. & Length of lines a yr Total length/size -� <br /> FILTER BED Distance to nearest: Well Foundation Property ine <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS IJ 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, 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 /> E this permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> The applicant m call for all �AQR <br /> Complete drawing on reverse side. ` 7� <br /> F Signed X / Title: Date: <br />' NT USE ONLY Stk 466-6782 <br /> Application Accepted by Area <br /> Additional Comments: :�� ig Lodi 369-3621 i <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final inspection by �'® Date (� Tracy 835-6385 <br /> Applicant - Return all copies to: Environment�Hth Permit/Services 1601 E. Hazelton Rv ,P.O. Box 2009, St k:, CR 95201 <br /> FFO <br /> BASE AMOUNT DUE AMOUNT REMITTED - - -RECEI-VED By DATE PERMIT N0. <br /> IN <br /> . � o <br /> 3/$ 73 <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />