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s <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEAtffH DISTRICT <br /> 1601 E. HAZELTON AVE,, STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <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 San Joaquin Local Health District. <br /> Jab Address Subdivision Name <br /> i <br /> Owner's Name Address Phone <br /> Contractor's Name License No, Phone <br /> i� <br /> TYPE OF WELL/PUMP WORK: NEW WELL .. Q WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION 0 SYSTEM REPAIR U y; + ,OTHER} 3 <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 d w .PROBLEM AREA CONSTRUCTION SPECI,FICAT'10% ----� <br /> ❑ Industrial U Open Bottom E] Manteca Dia, of Well Excavation <br /> 0 Domestic/Private ❑Gravel Pack Tracy Dia, of Well Casing <br /> 17 Public ❑ Other Delta <br /> Type of Casing <br /> U Irrigation Approx. Ej Eastern <br /> Cathodic Protection Depth Specifications <br /> Depth of Grout Seal <br /> L7 Geophysical_ ­ <br /> U Other - Type of'Grou# r <br /> Surface Seal Installed by 1 <br /> Repair Work Done ❑ Type of Pump N.P. State Work Done E <br /> Well Destruction U Well Diameters-eling Materiala(top <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION fJ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if-public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms T 'Lot si'ze <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Dj Type/Mfg Capacity G No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity I Method of;Disposal <br /> Septic Tank a 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 R.- Depth S.i.ze ,-Number-�..»,- - <br /> SUMPS .. L1; Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS a [� <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 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-" t <br /> The applicant must call for all required inspections, Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> t <br /> '' FOR DEPARTMENT USE ONLY <br /> Application Accepted by Area ❑ Stk 466-6781 <br /> Additional Comments: EJ Lodi 369-3621 <br /> Pit or Grout ,'Inspection by Date Manteca 823-7104 <br /> Final Inspection by\ Date Tracy 835-6385 �. <br /> Applicant Return all copies.Fto: ' Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201- <br /> I t <br /> 5201'' 6 <br /> FEE BASE I AMOUNT 'DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO., <br /> 1 INFO I <br /> i <br /> EH 13-24 REV.y.10/82 t '" ' 10/82 500 <br /> 14-26 ti 5 <br /> i <br />