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' APPLICAT10N FOR PERMIT <br /> SAN JOAQUi„' LOCAL H-E LTH DISTRICT <br /> 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED __1-!'C� <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 an Joaquin Loca Heal bpistr't.� fDQ���f / <br /> Job Address 73L <br /> �A ��•R.A (f(/ (� <br /> Owner's Name —1 �¢ hv?_ �ddress �� �� ,IgH� l3 ov Phone <br /> Contractor's Name (J t- S S License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS \ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial Cl Open Bottom J Manteca Dia, of Well Excavation <br /> (J Domestic/Private []Gravel Pack F]Tracy Dia. of Well Casing <br /> D Public J Other ❑ Delta Type of Casing <br /> J Irrigation Approx. J Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> ❑Geophysical Type of Grout <br /> Other Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> Well Destructionl< Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Jj REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) 4 <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 Ej Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM 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 Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <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 workmang 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 a r d in tion Complete drawing on��reverse side, <br /> Sign X isnt mu t call far 11 i 1 !rte Date: <br /> D RTMENT USE ONLY j Z ❑ <br /> Application Accepted by / Area Stk 466-6781 <br /> Additional Comments: EgL Lodi 369-36 <br /> Pit or Grout Inspection b Date J Manteca 823-7104 <br /> Final inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: En�entdl thPermit/Services 150 E. Hazelton Ave., P.O. Box 2009, Stk., CA - <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVE BY DATE PERMIT NO. <br /> INFO <br /> 82 50%��� <br /> EH 13-24 REV. 10/82si?, C3 <br /> 14-26 � . <br /> r- <br />