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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT r�7 <br /> i 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. ^I 1 4 <br /> Telephone (209) 466-6781 <br /> i- DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> tt. (Complete in Triplicate) <br /> 1 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 no Regulations of the Scan Joaquin Local Health District. <br /> Job Address Subdivision Subdivision Name <br /> h 112 Owner's Name , �` AddressOZY S - arc. Phone p <br /> Contractor's Name �� at 4 License.No. Phone � _ W <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TAN0 1 SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION .1 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TY?E'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1J Industrial U Open Bottom F_� Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack F_�Tracy Dia. of Well Casing <br /> PublicOther Delta <br /> �j Type of Casing <br /> Irrigation �Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal _ <br /> EJ Geophysical Type of Grout <br /> t_ <br /> {El Other Surface Seal Installed by <br /> Repair Work Done [J Type of Pump, H.P. <br /> State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') — <br /> Depth 11 Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION F-1 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> i available within 200 feet.) <br /> Installation will serve: Residence — Commercial Other x <br /> Number of living units: I Number of bedrooms i Lot size <br /> Character of soil to a depth of 3 feet: Water Compartments <br /> table depth <br /> No. Compart <br /> SEPTIC TANK Type/Mfg <br /> Capacity , <br /> PKG. TREATMENT PLT. F-1 Type/Mfg <br /> Capacity Method of Disposal <br /> { SEWAGE Distance to nearest: Well Foundation Property Line <br /> l FSTRUCTION 1%"AkFdoe ' <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> Property Line <br /> FILTER BED [� Distance to nearest: Well Foundation Pro p <br /> SEEPAGE PITS ❑ Depth : Size Number <br /> ± SUMPS El 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 /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applican m st 11 all`+required inspections.. Complete drawing on reverse side. 2— � y <br /> Signed X Title: �I Date: <br /> DEP TMENT USE ONLY Stk 466-6781 <br /> Application Accepted by _( (�� _ Area <br /> Additional Comments: Lodi 369-3621 <br /> Date L] Manteca 823-7104 <br /> Pit or Grout Inspection by <br /> � <br /> Final Inspection by .{ <br /> ( Date 3 �0 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 160 F. azelton Ave., P.O. Box 2009, St k., <br /> CA 95201 <br /> FEE. ;BASE RM011NT, DUE AMOUNT REMITTED RECEIV BY DATE PERMIT N0. <br /> INFO aye <br /> EH 13-24 REV. 10/82 10182 500�a C'�Y�/J` <br /> - 14-26 <br /> d <br />