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s { <br /> APPLICATION FOR PERMIT s <br /> ' SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 PERMIT NO. <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED 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"ReguTations of t San Joaquin Local Health District. , <br /> Job Address '�� -1 r <br /> Subdivision Name <br /> i Owner's Name Address Q <br /> i <br /> Contractor's Name Phone - " <br /> License No. O r Phone <br /> � - TYPE OF WELL/FUME WORK: NEW WELL WELL REPLACEMENT <br /> DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> F DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPD$AL FLD. IXgD PROP. LINE <br /> FOUNDATION Q AGRICULTURE WELL w OTHER WELL <br /> _ PITS/SUMPS <br /> INTENDED USE, <br /> *"%TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ti <br /> KOpen Bbttom Q Manteca Dia, of Well Excavation <br /> ADomestic/Private ❑Gravel Pack a r <br /> Tac ,.-gip .---.•� <br /> Public . .4 Y ,, Dia.-of Well`Casing <br /> �j Other Del to-- <br /> Li S. <br /> Irrigation 5�6) 1 Approx. Eastern Type of Casing -= 1 <br /> [] Cathodic Protection Depth Specifications <br /> Geophysical Depth of GroutSeal <br /> Other Type of Grout S9 / 'fix B+0t V , <br /> Repair Work Done Type of Pump Surface Seal Installed by <br /> H.p, ` <br /> State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501) — <br /> TYPE OF SEPTIC WORK: ,NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if <br /> ` tipublic sewer is <br /> Installation will server Residence _ CDmmercial Other available within 200 feet.) <br /> Number of living units; Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: <br /> SEPTEWater table depth <br /> £,�JANK , Type/Mfg Y Capacity` P y No. Compartments <br /> PKG.. TREATMENT PLT. Type/Mfg Ca acit <br /> SEWAGE SYSTEM p y Method of Disposal *- <br /> DESTRUCTION ❑ Distance to 'nearest:-'We]Well.. Foundation. Property Line <br /> e� :— <br /> LEACHING LINE U No. &"Length of lines Total length/size <br /> FILTER RED' Distance to nearest: Well Foundation ,.-_�y <br /> Property Line` <br /> SEEPAGE PITS Cj DepthSize Number T <br /> SUMPS L� Distance to nearest: Well �Eound3fioJn " s <br /> 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-}wand rules and regulations of the San Joaquin Local Health District. this <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which <br /> permit is issued, I shall not employ any person in such manner as to become subject toworkmank 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 st call for all required i ' <br /> q iLgpectians. Complete drawing on r rse side. <br /> Signed X Title: Date: <br /> [,,p FOR DEPARTMENT USE ONLY _ <br /> ��� G Replication Accepted by Area -- $tk 466-6781 <br /> Additional Comments: <br /> Lodi 369-3621 <br /> dr rou4 Inspecti;on4by Date �� Manteca 823-7104 <br /> l Final Inspection by Date �� <br /> _ V Tracy 835-6385 <br /> Applicant - Return all copienmental 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 /> EH 13-24 REV. 10/82 <br /> 14-26 10/82''500 <br />