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+ + APPLICATION .FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT d <br /> '! 1601 E. HAZELTON AVE., <br /> STOCKTON, CA r <br /> Telephone (209) 466-678I PERMIT No. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> (Complete in Triplicate) <br /> reby mad <br /> described. Thislication -is eapplicationoishmadeSan <br /> inocomplianceLocal <br /> wilthlth District <br /> Permit to construct and/or install the work herein' <br /> Joaquin County Ordinance No. 549 <br /> and the Rules and Regulations f San Jab Address San Joaquin Loc ealth Dist t. <br /> for sewage or No. 1862 for well/pump <br /> Owner's Name b sion Name <br /> Contractor's Name Phone f <br /> se No, <br /> Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL <br /> ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ❑ 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER <br /> f SEWER LINES i . DISPOSAL.FLO. <br /> FOUNDATION AGRICULTURE WELL PROP. LINE r <br /> OTHER WELL �� PITS/SUMPS V" <br /> INTENDED USE TYPE OF WELL PROBLEM AREA <br /> Industrial 14 <br /> CONSTRUCTION SPECIFICATION5 ' ' <br /> ❑Open Bottom <br /> Domestic/Private . ❑ Manteca , Dia, of Well Excavation <br /> ❑ Gravel Pack ❑ Tracy Dia. of Well Casing <br /> ❑ Public <br /> Lj Irrigation ❑ Other Delta❑ � T 1 <br /> 4 <br /> Approx. ❑Eastern s Type of Casing <br /> ❑Cathodic Protection Depth ispecifications <br /> ❑Geophysical +Depth of Grout Seal —� <br /> LJ Other F' - - <br /> Hype of Grout w. <br /> t <br /> Repair Work Done Type of Pump Surface Seal Installed by.y,,`. ' <br /> H P <br /> Well Destruction +❑ State Work Dane <br /> Well Diameter sealing Material (top <br /> Depth Filler Material (Below 50') ¢ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION <br /> ❑ REPAIR/ADDITIONi i . <br /> (No septic Pnk,or seepage pit-permitted—i-f--publ•iG­;5 ewer is <br /> Installation will serve: Residence _ Commercial Other iTable within 200 feet.) <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a depth of 3 feet: Lot size <br /> SEPTIC TANKType/Mfg TypWater table depth <br /> .,.. y <br /> PKG. TREATMENT PLT. Capacity No. Compartments <br /> e/Mfg r <br /> SEWAGE SYSTEM Capacity <br /> Method of Disposal M <br /> DESTRUCTION ❑� Distance to nearest: We71 Foundation <br /> Property Line <br /> LEACHING LINE �' <br /> No.r&T.Len' of lines <br /> I Total length/size <br /> FILTER BED H Distance'to nearest: Well <br /> Foundation Property Line g <br /> SEEPAGE PITS DepthSize 4 <br /> SUMPS _Vh4C_ Number 1 <br /> L_ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county f <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 sha <br /> Contractor's hirinll not employ any person in such manner as to become subject to workman§ compensation laws of California." <br /> g or sub-contracting signature certifies the following: <br /> this permit is issued, I shall empl ersors subject to workman's compensation rlaws oftify aCalifornit in the aerformance of the work for which <br /> The applicant m t f 4 <br /> Q 1 <br /> rewt inspection <br /> signed Xomplete drawing on reverse side. <br /> � <br /> Title: - Date: <br /> Application Accepted by F DEPARTMENT USE ONLY <br /> Area ` <br /> Additional Comments: Stk 466-67 1 <br /> Pit or Grout Inspection by <br /> L] Lod i 369- 21 <br /> Final Inspection by Date '�f ❑ Manteca 823-7104 <br /> Date v_v ❑ -Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIVED SY DATE PERMIT N0. <br /> EH 13-24 REV. 10/82 <br /> 14-26 10182 500 <br />