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+ > APPLICATION FOR PERMIT <br /> SAN JOAQJIN LOCAL HEALT.H_DISTRICT- <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. (J U <br /> Telephone (209) 466-6781 <br /> E f DATE ISSUED <br /> Y 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i 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 .5300 )ge ed e,Q _ Subdivision Name <br /> Owner's NameAddress } a Phone <br /> E Contractor's Name License No. Phone �/6c9 <br />! TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U w <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U l <br /> DISTANCE TO NEAREST: SEPTIC TANK 647 SEWER LINES _f e-a f DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> !�J Industrial U Open Bottom Manteca Dia, of Well Excavation 49 cs <br /> p <Domestic/Private g Gravel Pack ❑ Tracy Dia. of Well Casing <br /> r Public U Other Delta <br /> irrigation Type of Casing <br /> 9 Depthx �Eastern Specifications <br /> [�Cathodic Protection p - <br /> Depth of Grout Seal <br /> EJ Geophysical <br /> Type of Grout <br /> U Other <br /> Surface Seal Installed by <br /> Repair Work Dane [J Type of Pump H.P. State Work Dane <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> C) <br /> TYPE OF SEPTIC,WORK:_NEW,.INSTALLATION.U REPAIR/ADDITION D`(No septic tank or seepage pit permitted if public sewer is 'o <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 3tfeet: r Water table depth <br /> SEPTIC TANK 'U l� 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 <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED r Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Cj 'Depth Size Number <br /> SUMPS Distance to nearest-:. Well Foundation Property Line <br /> DISPOSAL PONDS <br /> r <br /> r 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 applicant must 11 or 11 r u' ins ections. Complete drawl on.reverse side. <br /> Signed X Title: _ Date: <br /> �� FjY�7DEP MENT USE ONLY <br /> Replication R pted by /� Rrea Q� Stk 466-678 <br /> Additional Comments: F] Lodi 364-3621 <br /> Pit or Grout Inspection by Date }G Manteca 823-7104 <br /> Final"Inspectian by - Date, ';? . L ,Tracy _ 835-6385.-- <br /> Applicant <br /> 35-6385 -.-~'Applicant - Return all copies to: Environmental Health 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 /> a-( 7�3 3-5o8 <br /> EH 13-24 REV. I0/82 / 10/82 500 <br /> 14-26 <br /> I <br />