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•¢ x <br /> APPLICATION FOR PER'lT <br /> SAN JOAQU2N LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. _'67S-LA1'L <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 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 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rules nd Re ulat' ns f be San J aquin L al alth District. <br /> Job Address Subdivision Name <br /> Owner's Name Address Phone CAL <br /> Contractor's Name icense No. Phone <br /> rp <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR L7 OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial (J Open Bottom Manteca Dia. of Well Excavation <br /> U Domestic/Private F-1 Gravel Pack Tracy Dia. of Well Casing <br /> 0 Public F-1 Other Delta Type of Casing <br /> V Irrigation Approx, E5 Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical <br /> Type of Grout <br /> U Other 6%Surface Seal Installed by O <br /> Repair, Work Done D Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ <br /> Depth- Filler Material (Below 50') Y �� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 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 <br /> Number of living units: J_ Number of bedroomsLot size <br /> 250 Character of soil to a depth of 3 feet: -vt— -T Water table depth Q <br /> SEPTIC TAMC Type/Mfg Capacity _ No. Compartments <br /> PKG, TREATMENT PLT. Type/Mfg Capacity Method of Dispos4l <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ' <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Wel l_ Foundation Property Line_ <br /> SEEPAGE PITS 7 Depth _ Size 3 x �'�„ Number <br /> SUMP:, Distance to nearest: Well Founda�n Property Line _ <br /> Z. 0 1DSSAL PONDS �I <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§ 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 to al for required inspect! s. Complete drawing on reverse side. F' <br /> Signed X Title: Date: <br /> OR PART NT USE ONLY <br /> Application Accepted by Area —.-._� % Stk '466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date U Manteca 823-7104 <br /> Final Inspection by Date '�3 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: 0211 <br /> ronmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTLD RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82i��l�J ��N'�J.� '1 { G1` 0/82 500 <br /> 14-26 <br />