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1 <br /> 1 fI APPLICATION FOR PERFiiT ` <br /> /�� SAN JOAQUiII LOCAL*Hi LTH D75-RICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-b781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED # <br /> i (Complete in Triplicate) y <br /> 1 - <br /> Application is hereby made to-the San Joaquin Local Health District for a permit to construct and/or install the work herein a <br /> described. This application is madelin compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wel3/pump <br /> and the Rules rd gulations of the- n Joaqui Local Health DistriFt. <br /> Job Address w / r QM44 on Name <br /> r <br /> Owner's Name61 Addres Phone <br /> Contractor's Nam ins- No. get Phan <br /> TYPE OF WELL/PUMP WORK: NEW WELL EjWELL REPLACEMENT—L] DESTRUCTION ❑ \ <br /> f y PUMP INSTALLATION I}( SYSTEM REPAIR ; � OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK j" SEWER LINES DISPOSAL FLD. PROP. LINE <br /> y FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial U Open Bottom �] Manteca Dia, of Well Excavation <br /> U Domestic/Private ❑Gravel Pack Tracy Dia. of Well Casing <br /> I] Public F-10ther Delta .Type of Casing 9 <br /> �V Irrigation Approx. Eastern ' <br /> Depth Specifications <br /> + <br /> ' Cathodic Protection - <br /> � <br /> Depth of Grout Seal <br /> Geophys`i-ca 1 <br /> " t Type of Grout <br /> Other f Surface Seal Installed by <br /> Repair Work Done [] Type of Pump 's H.P. State Work Don"e-Ai AL.P I <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ P <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPT IC'WORK:,,' NFW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer,is <br /> I I available within 200 feet.) <br /> _- Installation4Will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of,soil to_a_depth_o,f_:4fee1,:y____J_ _ __ _. r_ti _ Water table depth <br />- SEPTIC TANK ❑ Type/Mfg Capacity Nq,, Compartments <br /> +,y <br /> PKG. TREATMENT PLT. L] 'Capacity,�3 J,1 < va` 'Capacity ti Method of Disposal <br /> SEWAGE 'SYSTEM Distance to nearest: Well Foundation Property line # <br /> DESTRUCTION ! I <br /> LEACHING LINE + U No. & Length of lines e Total length/size s <br /> FILTER BED + Distance to nearest: cWell Foundation Property Line a <br /> SEEPAGE PITS Depth ISize Number r <br /> SUMPS y LJ Distance to nearest: "Well Foundation Property Line <br /> DISPOSAL PONDS x " <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. I <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 workmant compensation laws of California." <br /> Contractor's ring or sub-contrac ing ignature certifies ttL following: "I certify that in the performance of the work for which <br /> this permitf s issued, I shall em oy ,ersnns ubject to workman's c mpensation laws of California." <br /> The"appli t ust ca r all eq d in ction Complete w ng on reverse side. <br /> Signed X Title: Date: 1.,22!tj ► <br /> s`s ME ONLY <br /> k, Application Accepted Area E] Stk 466-6781 <br /> t Additional Coriments: Lodi 369-3621 <br /> . ' Pit or Grout Inspection by Date Manteca 823-7104 <br /> y Final Inspection byDate { ❑ Tracy 835-6385 <br /> ~t Applicant - Return all copies to: nvironmental Health rmit/Services 1 1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED '.i ''tRECE:IVED BY PERMIT NO. <br /> INFO �DATE <br /> J <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />