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APPLICA.TICN FOR PERMIT '. <br /> SA,N .CAQULN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 456-6781 SAM JDAQU�N LOCALOATF ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEjAL- lam <br /> w (Complete in Triplicate) <br /> i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to censtruct'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 d Subdivision Name <br /> Owner's Name �1r� (i, Address 0• �°`� /`1$1 Phone <br /> Contractor's Name d - - License No: 3 73Phone .� <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION ( SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Fl-D. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ?✓,� <br /> _ -Lndustr_ial _-z� U,Open .Bottom ;Manteca - -�---Y _ Dia..;:of_We1_l-Excavati.on � <br /> .- -:. - <br /> U Domestic/Private ❑ Gravel,P.ck Tracy Dia. of Well Casing <br /> �] Public [—I Other Delta Type of Casing <br /> L i Irrigation Approx. EJ Eastern Specifications <br /> F-ICathodic Protection Depth <br /> Depth of Grout Seal <br /> 1-1 Geophysical Type.of Grout <br /> U Other Surface Seal Installed by <br /> Repair Work Done E] Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) ��"._.✓ � -` <br /> Depth Filler Material (Below 50') <br /> N " <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIDN ❑ 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 d <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water.tahle depth <br /> SEPTIC TANKType/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 Fj Distance to nearest: Well Foundation property Line <br /> SEEPAGE PETS ❑ Depth Size Number <br /> +_4;__ SUMPS Distance to-nearest: Wel I=-- 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. i <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." _ 10 <br /> The applicant must call for all required inspections. Complete.drawing on reverse side. <br /> Signed K Title: Date: 10' <br /> EPA ENT SE ONLY <br /> Application Accepted by Area 5tk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date Y ❑ Tracy 835-63$5 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 . azelten Ave., P.D. Box 2009, Stk., CA 95201 <br /> I <br /> FEE $ASE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT NO. <br /> INFD <7�4 I__ d <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />