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APPLICATION FOR PERMIT <br /> SAN 30AQUiN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT <br /> Telephone (209) 466-6781 p <br /> DATE ISSUED 1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f <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 Regulations of_. the-/San Joaquin Local Health District. <br /> Job AddressI � r division Name <br /> Owner's Name Address-A&S 1. Phone <br /> r� l <br /> Contractor's Name License No. el Af phone <br /> I <br /> TYPE OF WELL/PUMP WORK: NEW WELL [] WELL REPLACEMENT DESTRUCTION U r <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC ,TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a <br /> Industrial LJ Open Bottom Manteca Dia. of Well Excavation <br /> U DomDia. of Well Casing <br /> [] Gravel Pack � Tracy 9 ,. <br /> Public LjOther Delta Type of Casing <br /> LJ Irrigation Approx. [] Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> 17 Geophysical Type of Grout <br /> U Other Surface Seal Installed by <br /> Repair Work Done �g Type of Pump%16 H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') — 0 : <br /> Depth Filler Material '{Below 50'} r`} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION LJ (No septic tank or seepage piavailaitted ifpublic <br /> within 200fseter is �. 1 <br /> Installation will serve: Residence Commercial i Other ll" <br /> Number of living units: Number of bedrooms Lot size <br /> Water table depth <br /> Character of soil to a depth of 3 feet: i <br /> SEPTIC TANK E-1 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> ! <br /> SEWAGE SYSTEM � Distance to nearest: Well Property P Y Line <br /> DESTRUCTION I <br /> LEACHING LINE U No. & Length of lines Total length/size J <br /> FILTER BED Distance to nearest: Well Foundation Property,Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS �� Distance to nearest: Well 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. <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 workmank 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 applicanj must 1 for all requ fired inspections. Complete dra ing on reverse side. <br /> Signed X <br /> II Title: Date: �. <br /> OR PEPARTM U Stk 466-6781 <br /> Application Accepted - Area _/ <br /> Lodi 369-3621 <br /> Additional Comme s: Manteca 823-7144 <br /> Pit or Grout I ction by Date <br /> Date Tracy 835-6385 <br /> Final Inspection by <br /> A pPlicant - Return all copies to: �viron�mentalHealth Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, St k., CA 95201 <br /> FEED BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY i PERMIT NO. <br /> E <br /> INFd1l <br /> III(! <br /> 10/82 500 <br /> F <br /> EH 13-24 REV. 10/82 2)l� jr <br />