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rz �9 <br /> ° "*MO' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781 _ <br /> DATE ISSUEDZ— <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 and Regulations of the San Joaquin Local Health'D1strict. <br /> Job Address 7 —"'subdivision Name <br /> Owner's NameA- AddressPhone <br /> Contractor's Name /j License No. _� ��� Phone 1 <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U" <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 U Open Bottom Manteca Dia. of Well Excavation <br /> Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing <br /> Public F-1 Other Delta <br /> F1 Irrigation Approx. Eastern Type of Casing <br /> Depth <br /> Specifications <br /> .. �Cathodic Protection p Depth of Grout Seal <br /> Ej Geophysical <br /> U Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction F-1 Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence Commercial _ Other available within 200 feet.) <br /> — Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: f- Water table depth /49 <br /> SEPTIC TANK Ej Type/Mfg Capacity No. Compartments _ <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines — Total length/size dR <br /> FILTER BED Distance to nearest: Well Foundation _Ii34p�J Property Line30 <br /> S� <br /> SEEPAGE PITS ❑ Depth Size ql Number <br /> SUMPS s{ Distance <br /> •t_oo nearest: Well l /s�; Foundation "�� -Pr�opoerty Line J"� <br /> DISPOSAL PONDS [J �an) , 5 Rr <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 sig ure certifies the following: "I certify that in the performance of the work for which <br /> this permit i ' sued, I shall employ per s^subject to workman's compensation laws of California." <br /> The applic t call for 1 req i d nyp9ctions. Compl in n reverse side. <br /> Signed Title: Date: L_ <br /> DEPARTMENT USE ONLY C1 <br /> Application Accepted by ` Area © S t k 466-6781 <br /> Additional Comments: U Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by �� � Date /2—22 L Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health ermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 in/R? rnn <br />