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APPLICATION FOR.PERMiT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT �(,,7P <br />1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. d -ll m�4✓ <br />Telephone (209) 466=61781-: <br />DATE ISSUED <br />PERMIT EXPIRES 1 YEAR FROMDATEISSUED <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 Sar 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 />Sob Address <br />Subdivision Name <br />Owner's E�Name Address Phone <br />Phone <br />Contractor's Name Lic_nse No. T e <br />il, <br />„TYPE OFIIWELL/PUMP WORK: NEW WELL WELL REPLACEMENT [] DESTRUCTION ❑ <br />IPUMP INSTALLATION SYSTEM REPAIR (] OTHER Ll <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO. e��PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER 1a ELL PITS/SUMPSB <br />INTENDED .USE,_,,,�,,., TYP&OF-WELL —PROSLEM-AREA..,,,,..... CONSTRUCTION,SPEC-IF.ICATIONS- --*--�--*---- <br />r�G > <br />IJ In dustrial U Open Bottom Manteca Dia. of Well Excavation _ 4 � <br />Domestic/Private � Gravel Pack �f Tracy Dia. of Well Casing ����-� <br />PublEic Other Delta Type of Casing <br />Ll Irrigation Approx. E] Eastern Specifications; <br />Catfiodic Protection Depth <br />Depth of Grout Seal <br />Geophysical Type of Grout r <br />LJOther r - <br />-_ �`"""""'""`"- " ' � � � '� � ~ 'Surface Seal Installed by <br />Repair Work Done G Type of Pump H. P. State Work Done <br />a <br />Well Destruction U Well'biameter �Seal'ing'Material (top 50') - <br />iv <br />.!. Depth. _,Filler'"Material (Below 50') <br />f, <br />TYPE OF SEPTIC WORK: NEW INSTALLATION El 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 <br />Number of living units:. Number of bedrooms- -'-- Lot size <br />Character of soil to a depth of 3 feet: k Water table depth <br />SEPTICtTANK [] Type/Mfg Capacity t No. Compartments <br />PKG. TREATMENT PLT. Type/Mfg i �} Capacity Method of Disposal <br />SEWAGEt.SYSTEM Distance to nearest: Well Foundation Property Line <br />DESTRUCTION # <br />LERCHI' G LINE U No. & Length of lines Total length/size <br />Property Line <br />FILTERIBED �. Distance to nearest: Well Foundation P <br />11 . <br />SEEPAGE PITS Cj Depth Size Number ' <br />SUMPSj� �� Distarce to nearest: Well Foundation Property Line <br />DISPOSAL PONDS CI <br />�Y <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's 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 a�ppli s ca 1 or 11 required inspections. Complete drawing o reverse side <br />Title: Date: <br />Signed <br />i <br />�N R DEPART M hT USONLY 'rea Stk- 466-6781 <br />Application Accep d by <br />Lodi 369-3621 <br />Additional Comments: <br />Pit or Grout Inspection by Date LJ Manteca 823-7104 <br />Final Inspection by Date U �'' Tracy 835-6385' <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazel or P: O."Boz 2009; Stk` CA 95201 <br />FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br />INFOR-tl-�y ?q~ {f(,7 �i +� <br />w�li <br />O/BP 500 <br />EH f3-24 REV. 10182 <br />