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APPLICATION. FOR PERMIT <br /> USAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, — <br /> Telephone (209) 466-6781 x' oZ <br /> DATE ISSUED <br /> PERMIT EXPIRE$'L YEAR FROM DATE ISSUED / <br /> (Complete -in Triplicate) , <br /> r <br /> Application is`hereby•made to the San Joaquin Loca1'Health District for a permit to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquir County Ordinance No. 544 for sewage dr No. .1862 for well/pump <br /> and the Rules and Regulations At Sar Joaquin Loc 1 Health District, s <br /> Job Address Subdivision Name <br /> Owner's Name7 71 ImUress Phone <br /> Contractor's Name ' Vicense No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUETION ' lJ <br /> PUMP INSTALLATION'S ❑ SYSTEM REPAIR OTHER <br /> " 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD•- PROP. LINE <br /> FOUNDATION'S AGRICULTURE"WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �) <br /> I. !tD Industrial 00 pen Bottom Manteca Dia. of Well Excavation } <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing17 ' <br /> Public Other Delta Type of Casing <br /> Fj Irrigation y Approx. EJ Eastern <br /> Cathodic Protection Depth Specifications - <br /> ~ Depth of Grout Seal ` <br /> Geophysical . . � _. o-_�. <br /> Other FT TY pe ofGrout <br /> Surface Seal Installed by lJl <br /> Repair Work,Done Type of Pump r H.P. State Work-Done F C) <br /> Well Destruction LI Well Diameter ) Sealing Material (top.,50')i <br /> _ � <br /> Depth Filler Material (below 50') <br /> •TYPE OF SEPTIC WORK: NE14 INSTALLATION REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is {� <br /> ' ., available withi <br /> r n 200 feet.) <br /> Installat"ion will serve: Res"idenc eA C6mmercialx Other <br /> l <br /> Number"of living units: 8 } Number of bedrooms _ Lot size . <br /> Character of soil to a depth `o;f 3 feet: = Water table depth <br /> SEPTIC TANK Cj Type/Mfg Capacity _ No. Compartments <br /> { PKG. TREATMENT ALT. F-1 Type/M.g -,.Capacity Method.'o 0isposa1 <br /> SEWAGE'SYSTEM ��•--1� Distance to nearest*.'-Well4 Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE No. &. Length of lines Total length/size 3 r <br /> FILTER BED Distance to nearest: Well j' Foundation Property Line <br /> SEEPAGE PITS Depth` ` Size Number ! <br /> .y <br /> SUMPS L-1 . Distance to nearest- ell Foun tion "Property Line <br /> DISPOSAL PONOS <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> t 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 /> f Contractor's Hiring or sub=contracting signature certifies'the following: "I certify that in the performance ofthework for which <br /> this permit is-issued, I shall employ persons subject to workman's compensation laws of California." <br /> y The applican 'm call for required ins ec ns. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> Date: <br /> P MENT U NLY <br /> Application Accepted Area E] Stk 466-67 <br /> Additional Comment Lodi 369-3 1 <br /> ' Pit or Grout Inspection b Date -9_o6—R3'-- Manteca 823-7104 <br /> Final Inspection'by " ? Date--2 L Tracy 835-6385 <br /> Applicant - Return all copi Environmental Healthr'Permit/Services' 1601 E. Hazelton Ave., P.O. Box 2009," St k., CA 95201 <br /> ' FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PFRMIT NO, <br /> INFO <br /> EI 13-24 REV. 10/82 10/82 500 r, <br /> 14-26 <br />