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APPLICATION FOR PERMIT p $ <br /> yk..1 Rf: <br /> i-4—— SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601.E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 J, DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM'-.DATE ISSUED <br /> (Complete in Triplicate) dQ <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. Joaq in Local Health District. <br /> x <br /> Job Address Subdivision Name <br /> Owner's Name Address �,t}ivt _ Phone gs —,?Jo <br /> Contractor's Name e,No. J:?, f �{ Phone o <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ] DESTRUCTION F-1 } <br /> PUMP INSTALLATIOP, E] SYSTEM REPAIR P OTHER [:]DISTANCE TO NEAREST: SEPTIC TANK ��(} �' SEWER LINES ��G7 t DISPOSAL FLD. � PROP. LINE Z6 �f <br /> FOUNDATION ;l Q �4 r AGRICULTURE WELL �[� �+ -_ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. * `' <br /> ❑ Industrial ❑ Open Bottom 'D.MantDia. of Well Excavation <br /> Domestie a c/Private Gravel Pack Tra y = Dia, of Well Casing <br /> 1-1 Public Ej Other E I to Type of Casing <br /> Irrigation � L^� Approx. Eastern 4 <br /> Ll <br /> 7/,;z Depth Specifications <br /> [] Cathodic Protection Depth of Grout Seal <br /> j�Geophysical \. <br /> Type of.Grout, C_rI`Y7 <br /> j�Other ' <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. _ State Work Done i <br /> Well Destruction U Well Diameter SealingTMaterial (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Lf REPAIR/ADDITION U'(Naseptic 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 bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Cj Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ Type/Mfg Capacity Method of Disposal <br /> Septic TankO Distance to nearest: Well Foundation Property Line <br /> Destruction <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth i Size Number <br /> SUMPS Lj Distance to nearest: Well Foundation Property'Line _ <br /> DISPOSAL-PONDS ❑ <br /> 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: "1 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-contractinq signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, s all -o .persons subject to workman's compensation laws df California." <br /> The applic u ca all a ired spections. Complete drawing on r erse side. <br /> Signed XTitle: Iryn.( Dater <br /> D PARTMENT USE ONLY <br /> Application Accepted by Area �— ❑ 5tk 466-3621 <br /> F <br /> Additional Comments: [] Lodi 369-3621 <br /> Pit or Grout Inspection Date ,,,Manteca 823-7104 <br /> Final Inspection by Date 2 Tracy 835-6385 - <br /> Applicant - Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton ., P.O. Box 2009, Stk., CA 95201 <br /> FEE!l "`BASE AMOUNT DUE1 AMOUNT REMITTED RECEIVED BY DATE PERMIT N0, f <br /> INF.9 <br /> ea <br /> EH 13-24 REV, 10/82 10/82 500 <br /> 14-26 <br />