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l APPLICATIONN FOR PERMIT <br /> r <br /> SAN JOAQbiN LOCAL HEALTH ,1ST.RICT <br /> i 1601 E. HAZELTON AVE., STOCKTON, CA 3-607 <br /> PERMIT N0. <br /> 1 Telephone (209) 465-6781 OJ <br /> 4 DATE ISSUED J <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED- <br /> i (Complete in Triplicate) <br /> Application is hereby made to the Sari 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 ns o��f��//tpe San Joaquin Local. Health District. <br /> Job Address =� Cvl9 4 le Subdivision Name <br /> Owner's Name irfo 0 Address Phone <br /> Contractor's Name License No. �J 5Z Phone — � <br /> TYPE OF WELL/PUMP WORK: NEW WELL F WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTiiiALLATION SYSTEM REPAIR OTHER U 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — 0 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J <br /> J Industrial U Open IBottom ❑ Manteca Dia. of Well Excavation <br /> L_I Domestic/Private ❑ Gravel Pack Tracy Dia, of Well Casing <br /> Public <br /> L7 �{ Other Delta <br /> Type of Casing <br /> Li Irrigation .Approx. Eastern <br /> ❑ Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done Ej Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter} Sealing Material (top 50') _ <br /> Depth I Filler Material (Below 50') 0r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/,ADDITION 0 (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br />:i Installation will serve: Residence Commercial Other t/ ' <br /> Number of living units: }Number of bedrooms Lot Size <br /> Character of soil to a •depth of 3 feet: Water table depth <br /> SEPTIC TANK U Type/MfgI Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Type/Mfg' Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance:to nearest: Well Foundation Property Line <br /> DESTRUCTION lJ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br />` FILTER BED Distance ito nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> j <br /> SUMPS Distance.to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D <br /> fff r <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 inust 1ZrI <br /> 1 re u ed inspections. Complete dr wing vn—reverse side. <br /> Signed X Title; , C _ Date: <br /> F DEP TMENT JSE ONLY <br /> Application Accepted by Area O3 5tk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by I Date Manteca 823-7104 <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant - Return all copie o:' Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 <br /> FFEE BASE RM011NT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> 1 <br /> INFO <br /> EH 13-24 REV. 10/82 <br /> �. � 10/82 500 <br /> 14-26 P� L€"ti ��� <br />