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fl APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. J1—IS3 <br /> l Telephone (209) 466-6781 <br /> F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> (Complete in Triplicate) M <br /> Application is hereby made to the San Joaquin Local Health District fora 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 o�he �oaqui cal Health District. <br /> Job Address Subdivision Name <br /> Owner's Name Address a Phone <br /> w <br /> Contractor's Na i A Z4 No. P h a <br /> _-'_ -_ <br /> TYPE OF WELL/PUMP WORK: NEW W L WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR `OTHER <br /> ..DISTANCE.-.TO-NEAREST-:-SEPT-IG—TANK---Z *�Z -SEWER--LINES.---• .RROP_L-INE_ - <br /> FOUNDATION AGRICULTURE WELL r OTH6WELL\_A^-4. ,PITS/SUMP,S�.� i <br /> - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Indu rial pen Bottom [] Manteca Dia, of Well Excavation `/-a' O' <br /> mestic/Private ❑ Gravel Pack Tracy Dia. of Well Casinq A0 •J <br /> L7 Public FJ OtherDel to;, - <br /> } Type of Casing <br /> Irrigation a <br /> V 4 Approx. � Eastern - -Specifications _ <br /> Cathodic Protection . <br /> Depth _ <br /> Depth of Grout Seal <br /> Geoph`gsi'cali? �� i ) ! r <br /> Type of Grout 4wr <br /> Other <br /> Surface al <br /> -Seal Ihs _led by r - <br /> Repair Work Done.Q Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') _ 0 <br /> Depth Filler Material (Below 50') ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U. REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer" is -� <br /> I available within 200 feet.) <br /> Installation will serve: 'Residence Commercial Other " ` <br /> Number of living units: Number of bedrooms Lot size r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK� ,, - <br /> Capacity No. Compartments <br /> PKG."TREATMENT PLT. ❑ Type/Mfg, Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE No: & Length of lines Total length/size <br /> FILTER BED Distance, o.nearest: Well �:Foundation_ ---YP_roper�y;lane�—. <br /> SEEPAGE,PITS a:. Depth Size ` Number <br /> SUMPS U Distance to nearest: Well 'Foundation Property Line <br /> DISPOSAL PONDS �: a <br /> I hereby certify that I havelprepared 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 /> Contractor's hiring or sub-contractin s gnature <br /> certifies the following: "I certify that in the performance of the work for which <br /> this,permtt is, ed, I shall empl y p rsons subject to workman's&coensation laws of California." <br /> The applican mus 11 for all re d ins ctions. Complete drev se side. <br /> Signed X I if A X Title: IDate: s <br /> DEPARTM T USE NLY �( <br /> p c io cued byArea _ �] Stk 466-6781 <br /> Additional Oomments: Lodi 369-3621 <br /> Pit or rou Inspection by Date '1 C� Manteca 823-7104 <br /> Final Inspection by' Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environme al Health Permit/Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, ' <br /> INFO <br /> a o k, g — S3 <br />_ u <br /> EH 13-24 REV. 10/82 10/82 500 <br /> y 14-26 <br />