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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Tel-nphone (209) 466-6781 <br /> GATE ISSUED <br /> PERMIT EY.PIP.ES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicates <br /> Application is hereby made to the San uoaquin Local Health District for a permit to construct and/or install the work herein <br /> described, "his 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 L,9cal Health District, - <br /> Job Address_ <br /> ��'a/. _Subdivision yams <br /> Owner's Name ti CLJscAddress <br /> i Contractor's Name License No. _��� Phone 0 ; -GGSoZ� <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION (J SYSTEM REPAIR ❑ OTHER Lj s <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LiNE d <br /> FOUNDATION AGR;CULTURE WELL OTHER WELL PITS/SUMPS p� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> (� Industrial U Open Bottom ❑Manteca Dia. of Well Excavation <br /> 117 Domestic/Private Gravel Pack ❑Tracy Dia. of Well Casing g <br /> r". Public Publa <br /> L7 LJ Other ❑De i to <br /> C] Irrigation Type of Casing <br /> 9 Approx. EJ Eastern Specifications <br /> Cathodic Protection `Depth D <br /> Geophysical <br /> Depth of Grout Seal <br /> Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done [_J Type of Pump H.P. _State Work Done 3 <br /> Well Destruction Lf Well Diameter Sealing Material (top 50') ' <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LJ (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: Number of b ooms Lot size �/ 1c'. y 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPi1C TANKType/Mfg t _ Capacity \�LJ,L� No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. d Length of lines CXi Total length/size Zp�� <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11f6_ Depth \Q Size 5N,x Number <br /> SUMPS Distance to nearest: Well Foundation _ Property Line 1e, <br /> DISPOSAL PONDS ID ` <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 workmans 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 1 all required inspections. Complete drawing n reverse side. <br /> Signed %��(/�� _ Title: ������ Date: <br /> FOR DEPARTMENI USE ONLY <br /> Application Accepted by Area E] Stk 466-6781 <br /> Additional Comments: Lodi 369-'621 <br /> Pit or Grout inspection by Date p&Manteca 823-7104 <br /> Final Inspection by Date `— Tracy 835-6385 <br /> Applicant - Return all copies to: En v i ronmen ta',,.0 kalth Permit/Services 1601 E. Hazeltcn Ave., P.O. Boz 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY GATE PERMIT N0. <br /> INFO <br /> CH 14-26 REV. 10182 �����_.I_ I 10/82 500 / zq <br />