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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HERLTH DISTRICT ,� L 19$3 1 ip -23 3� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 SAP; .toA�QtjjOnALDATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEALTH d)ISTR!CT <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 Regul tions o the San Joaquin Local Health District. <br /> Jab Address 5t Supbdivis o(,� Name <br /> Owner's Name ddres p a `{ Phone <br /> Contractor's Nameno,m ajo-66 X110License No. n/ � - Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] ,WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U w <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE �1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ZInd trial U Open Bottom Manteca Dia. of Well Excavation <br /> omestic/Private r-­] Gravel Pack Tracy Dia, of Well Casing <br /> Public F-1 Other [} Delta Type of Casing <br /> LjIrrigation Approx. ❑ Eastern <br /> Cathodic Protection <br /> Depth Specifications <br /> Depth of Grout Seal <br /> ❑Geophysical <br /> Type of Grout <br /> U Other ` Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. I/O State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') W <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) —S) <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 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM rr---� Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION L 1 <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS CI <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 worknanh 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/ils <br /> ued, I shall employ persons subject to workman's compensation laws of California." <br /> The appy st cal for equir in spec s. Complete wing on rever side. <br /> Signed X T' le Date: <br /> F�1 DEPA ONLY <br /> Application Accepted by , /La Area Ers-tk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by i Date Z 7 c Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE ?PERMIT NO. <br /> INFO , a} J <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />