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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH 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 Requlatio of the.S n Joa in Local Health District. <br /> Job Address—i A S -&51NA <br /> t Owner's Name Address / Phone <br /> Contractor's Name <br /> License No. °' 2. es Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> F PUMP INSTALLATION ❑ SYSTEM REPAIR L] OTHER ❑ �A1 <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 PROBLEM AREA CONSTRUCTION SPECIF-ICATIONS f �J <br /> FJ Industrial ❑Open Bottom ❑Manteca `- . Ria. of.Weil Excavation a <br /> ❑-Dome sticIRdyate__: ❑-Gravel-Pa ck.-._-�,_[f Tracy Dia. of Well_Gasing� <br /> ❑ Public ❑ Other ❑Delta-, Type of Casing <br /> CJ Irrigation Approx. [] Easte�n Specifications <br /> Cathodic Protection Depth ✓ <br /> F-1Depth of Grout Seal <br /> ❑Geophysical i �! Type of Grout <br /> ❑Other �,_ Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. / { State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION 211% septic tank or seepage pit permitted if public sewer is <br /> /� available within 2D0 feet.) <br /> Installation will serve: Residence ✓ /Commercial Other <br /> Number of living units: �_ Number orf b drooms j Lot size <br /> Character of soil to a depth of 3 feet- / x a. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg �ti, Capacity d No..Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM c Distance to nearest: `Well. Foundation Property Line <br /> DESTRUCTION <br /> I LEACHING LINE No. & Length of lines � `-"�'���T"-'"""""'Total--L-length/size­ <br /> FILTER BED ❑ Distance to nearest: Well ! Foundation I ( Property Line <br /> ' SEEPAGE PITS Depth ��� / Size, "Number L_ <br /> SUMPS U Distance to nearest: Well ` 0-0 Foundation _ / _ Property Line <br /> DISPOSAL PONDS - <br /> ❑ ��7- --'� <br /> t <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 asto become subject to,workman compensation laws of California-" <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certifyithat 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 /> + The applica t m st call for all re u' ed ns ections. Complete dra Ing on reverse s-ide�. I f �T <br /> Date: <br /> Signed X q- � P Title: ,' - <br /> FOR DEPARTMENT USE ONLY <br /> App kation Accepted by �. A 4 r J Area ❑ Stk 466-6781 <br /> Additional Comments: <br /> -{ .K ,- r Lodi 369-3621 <br /> Pit or Grout Inspection by Date /D-'Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant -Return all copies Environmental Health Permit/services 16 E.&a,,lto, Ave., P.D. Box 2009, St k., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> { l ja / ✓ IQV <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />