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L " APPLICATION FOR PERMIT o+ <br /> 4 I SAN JOAQUIN LOCAL HEALTH,DISTRICT r r <br /> 1{ 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 'C�.\ <br /> Telephone (209) 466-6781 <br /> ' DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in.Triplicate) <br /> I 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 <br /> 1f <br /> 11 oa uin Local Health District. <br /> Job Address Subdivision Name <br /> Owner's Name Address Phone <br /> Contractor's Name icense No. Phone <br /> i TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT - DESTRUCTION . <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR �` OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANKISEWER LINES DISPOSAL FLO. PROP. LINE V 1 <br /> FOUNDATION -` AGRICULTURE WELL OTHER WELL PITS/SUMPS GJ <br /> ` INTENDED USE TYPEIDF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , <br /> f Industrial U Open Bottom F� Manteca Oia. of Well Excavation <br /> L4 Domestic/Private []Gravel Pack Tracy Dia. of Well Casing <br /> �] Public [j Other Delta Type of Casing <br /> V Irrigation Approx. Eastern Specifications 2, <br /> Cathodic Protection Depth <br /> u i Depth of Grout Seal <br /> Geophysical Type of Grout <br /> r ❑Other Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done IV <br /> Well Destruction F-1WellDiameter Sealing Material (top 5D') <br /> Depth Filler Material (Below 50') <br /> 3 I(A <br /> M U REPAIR/ADDITION y ' (No septic tank or seepage pit permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION <br /> "r available within 200 feet.) <br /> Installation will serve: Residence !.- Commercial Other �yL� <br /> Number of living units: (f Number of bedrooms Lot size /. <br /> Character{of soil to a d th df 3 feet: ,P�-+-� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capaq Y. No. Compartments <br /> LA <br /> PKG. TREATMENT PLT. E] Type/Mfq Capacity„ Method of Disposal <br /> r <br /> SEWAGE SYSTEM - Distance to nearest: Well p Foundation—1 3i Property Line <br /> DESTRUCTION <br /> LEACHING LINE J_R No. &'Length of lines yp Total length/size Q <br /> FILTER BED ❑ Distane to nearest: Well ' Foundation Property Line <br /> SEEPAGE PITS ( ] Depth ' Size _23 Number r � � <br /> { SUMPS �a L� Distance to nearest: Well .tFoundation _ Property Line <br /> DISPOSAL PONDS �I <br /> I hereby Y certif '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 /> Rome owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is is5ued, 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 following': ``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 /> f The applicant us all for brequired ins ctions. Complete drawing on reverse side. <br /> Signed XTitle: [�O/�fa� __ Date: <br /> yy�� OR PARTMENT USE ONLY Stk 465-fi7$1 <br /> Application Accepted by" /C • Area 02, <br /> Additional Comments: EJ Lodi 369-3621 <br /> Pit or Grout Inspection;by Date Manteca 823-7104 <br /> S Final Inspection by Date} '��J L Tracy 635-6385 <br /> Applicant - Return all co <br /> to. <br /> Environmental Health Permit/ServiCeS 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> =INFO <br /> AMOUNT-DUE AMOUNT REMITTED RECEIVED BY DATE ��IPIERMIT N0. <br /> sp ( ,� 13 � <br /> M <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br />