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L <br /> APPLICATION FOR PERMIT <br /> SAN jCAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. -,-7�� <br /> Telephone (209) 466--6781 DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> A <br /> Application is hereby ade t6 the <br /> Saninodquir anc heaithlth <br /> Districn County p0rdinanee No5t549tfor dsewage sorlhrherein <br /> Not1862forwelllpump <br /> s made <br /> described. This app <br /> and the Rul*andgulatiens of the San Joaqu n Local Health District, <br /> Job Address 5ubd9yision Name <br /> s Phone Owner's NamAddressPhoneicense No.Contractor' h <br /> TYPE OF WELL/PUMP WORK: NE11 WELL �] WELL REPLACEMENT DESTRUCTION ❑ d <br /> OTHER <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> DISPOSAL FLD.D. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK __T� SEWER LINES PITS/SUMPS <br /> -FOUNDATION <br /> AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 <br /> (J Open Bottom Manteca Dia. of Well Excavation <br /> �J Industrial r <br /> ❑ Domestic/Private Gravel Pack ❑Tracy Dia. of Well Casing <br /> p <br /> ❑ Public other, ❑ Delta Type of Casing <br /> A rox. asSpecifications <br /> Z <br /> Irrigation PP Eastern❑ P � f <br /> ❑Cathodic Protection <br /> Depth Depth of Grout Seal <br /> Geophysical Type of Grout <br /> ❑Other Surface Seal Installed by <br /> Repair Work Slone E) Yp <br /> Type of Pump f H.P. State Work Done <br /> Well Destruction ED Well Material (top 50')Well Diameter . <br /> Y Depth Filler Material (Below 50') <br /> No septic tank or seepage pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U ( available within 200 feet.) p <br /> installation will serve: Residence Commercial Other / `3 <br /> Number of bedrooms Lot size <br /> Number of living units: Water table depth <br /> Character of soil to.a- depth of 3 feet: No. Compartments <br /> Capacity <br /> SEPTIC TANK Type/Mfg Capacity Method of Disposal <br /> PKG. TREATMENT PLT. Type/MfgLine <br /> SEWAGE SYSTEM . Distance to nearest: Well <br /> Foundation � — ProQerty <br /> DESTRUCTION` # <br /> �- 'XO 6 . Total length/size � <br /> LEACHING LINE No. & Length of lines / Property Line <br /> Distance to nearest: Well � Foundation _ G <br /> FILTER BED - <br /> ❑ Depth <br /> Size <br /> SEEPAGE PITS' Number <br /> ell Foundation Property Line <br /> SUMPS Distance to_ nearest: W �� <br /> DISPOSAL PONDS ❑ <br /> 4 <br /> ! I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ,4 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner yr licensed agent's signature certifies the following: "I certify that in the per <br /> of the work for which this <br /> performance of the work for which <br /> f permit is issued, I shall not employ any person in such manner as to become subject to workman+ compensation laws of California. ' <br /> 1 Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the p <br /> joy persons subject to workman's compensation laws of California." <br /> this permit is issued, i shall emp ��/S <br /> ` G <br /> ' The applicant must call for all required inspections. Complete drawing on reverse side. Date: <br /> Title: <br /> Signed X <br /> R DE M US NLY Area ®/ ❑ Stk 465-6781ir <br /> Application Accepted by c�L 1 Lodi 9-3521 P1 f <br /> Additional Comments: �_� ❑ Manteca 823-7104 <br /> Date <br /> Pit or Grout Inspection by 835-6385 <br /> Date Rton <br /> L TracyFinal Inspection by t : . Environmental H alth Permit/Ser..v_ices 1601 E. Ave., P.O. Box 2004, Stk., CA 95 <br /> Applicant_ Return all copies201 <br /> FEE <br /> DATE PERMIT N0. <br /> BASE AMI)INT�DUE AMOUNT REMITTLO <br /> RECEIVE0 8Y <br /> INFO o <br /> y� 5 <br /> lD/az 500 <br /> EH 13-24 REV..10/82 <br /> 14-26 <br />