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APP)1CATION FCR PER�VI T <br /> SA.N JOAQLi N LOCAL HEALT: DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-5781 <br /> DATE ISSUED <br /> PERMIT EXPIRES I 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 Regulation% of t e San Joaquin Loc alth District. <br /> Job Addres N 1 S <br /> kry ) <br /> Owner's Nam Address / aj;pez <br /> Phone <br /> Contractor's am ' License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL F7 WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER (:J- <br /> DISTANCE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR03LEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> U Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing <br /> Public F-1 Other Delta Type of Casing <br /> V Irrigation Approx. E] Eastern <br /> Depth Specifications <br /> ❑Cathodic Protection Depth of Grout Seal <br /> F1 Geophysical <br /> Type of Grout <br /> L1 Other l <br /> Surface Seal Installed by l� <br /> Repair Work Done E] Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below SO') O� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L— REPAIR/ADDITION [: (No septic tank or seepage pit permitted if public sewer is fV„1 <br /> / <br /> Installation will serve: Residence k Commercial _ Other available within 200 feet.) <br /> Number of living units: Number of a rooms Lot si 4Z<__ <br /> r7 <br /> Character of soil to a. depth of 3 et: Water table depth ��Lr <br /> SEPTIC TANK �! Type/Mfg Capacity �_ No. Compartments <br /> PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well c2C `.Foundation /�` Property Line <br /> DESTRUCTION <br /> LEACHING LINE No. & Length of lines G Total length/size <br /> FILTER BED Distance to nearest: Well neFoundation Proper <br /> y Line {— <br /> SEEPAGE PITS Depth Size " Numbers <br /> SUMPS Distance to nearest: Well Foundatior _ 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 workman compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the fallowing: "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 applica must call r a required inspections. Complete drawing on r verse side. <br /> Signed X Title: IzJI Dater <br /> FOR DEPARTMENT USE ONLY <br /> Ap0ition Accepted by Area C7 Stk 466-6781 <br /> Adnal Comments: Lodi 369-3621 <br /> Pit or Grout Inspection Date Manteca 823-7104 <br /> Final Inspection by Date �� Tracy 835-6385 <br /> Applicant - Return all copies to: En vi onment 1 ea th Permit/Services 1601 .E. H zelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO 7 1'093 ­�3-_�'+� <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />