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A <br /> APPLICATION FOR'PERMIT <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT q <br /> 1601 E. HAZELTON AVE., STOCKTON. CA -PERMIT NO. <br /> Telephone (20 9) 466-_6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES I YEAR FROM 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 mede'in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules and Re ulations of the San Joaquin Local Health District.. <br /> Job Address t& .A Subdivision Name <br /> Owner's NameL� Address one <br /> Contractor's Name s License No. �.. Phone <br /> TYPE OF WELL/PUMP WORK: NEW;WELL ❑ WELL REPLACEMENT [] DESTRUCTION <br /> PUMP INSTALLATION [] SYSTEM REPAIR OTHER EJ <br /> DISTANCE'TO NEAREST: SEPTIC -TANK SEWER LINES DISPOSAL FLD. PROP, LINE �] <br /> F_pUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial:_;iOpen,Bottom Manteca Dia. of Well Excavation <br /> 'Domestic/Private ; Gravel Pack Tracy Dia, of Well Casing <br /> E] Pdblis E],OtherrElDelta <br /> Irri Type of Casing <br /> LJ gallon ', x pepp ❑x. Eastern Specifications <br /> [] n Cathodic Protection pth4. <br /> Geophysical Depth of Grout 5eai <br /> Other a t vI Type of Grout , <br /> Surface Seal Installed by <br /> Repair Work Done E] Type of Pump �. M.P. <br /> State Work Done -; r <br /> Well Destruction . ,Well' Diameter i= Sealing Material (tap 501) <br /> Depth y f 'Filler Material (Below 501) <br /> TYPE OF-SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage pit permitted if putilic,sewer is <br /> Installation will serve: Residence � Commercials` Other available within 200 feet.) � <br /> Number of living unifs: Number of bedrooms 3 Lot size <br /> Character of soil to a:depth of 3'feet: Water table depth <br /> SEPTIC TANK, T# <br /> 3; ❑ ype/Mfg Capacity �rNo:�Compartments <br /> PKG. TREATMENT^PLT T e/Mf '� I <br /> r ❑ YP 9 Capacity Method of Disposal <br /> 1 Distance to nearest Well Foundation Property Line <br /> r <br /> LEACHING LINENo. & Length of lines _ 1 Total length/size C3T �? <br /> FILTER BED Distance to nearest Weil ►'So Foundation Property Line ,ova✓ /p+ <br /> SEEPAGE,PITS d Depth 4 Size `Numberr� "~ <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> t <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 applicant must call for 11 re uired inspections. Complete drawing on reverse side. <br /> Signed X r' Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Area E3Stk 466-6781 <br /> Additional Comments: qLodi 369-362.1 <br /> Pit or Grout Inspection by 1 ` Date Manteca 823-7104 F <br /> Final Inspection by "-" a}� to' - C] Tracy 635-6385 <br /> Applicant - Return all copie to: 'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFO DATE PERMIT NO. <br /> EH 13-24 REV. 10/82 <br /> 14-26 10/82 500 <br />