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APPLICATION FOR PERMIT <br /> SAN ]OAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO.� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED 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.th ul .s r' Re la 'ons f,the San ioaquin Local Health District. <br /> Job AdSubdivision Name <br /> Owner's Name Address f Phone <br /> Contractor's ame d C License No. wS 7 Z/ Phone <br /> TYPE OF WELL/PUMP WORK:- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I <br /> PUMP INSTALLATION (❑ SYSTEM REPAIR ❑ OTHER ❑ �} <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ; <br /> f <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> Industrial ❑Open Bottom ❑ Manteca ' Dia. of Well Excavation <br /> ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Di'a. of Well Casing <br /> ❑ Public ❑ Other ❑ Delta r <br /> ❑j <br /> Type of Casing <br /> irrigation Approx. ❑ Eastern <br /> ❑Cathodic Protection Depth Specifications 41 <br /> Depth of Grout Seal <br /> ❑Geophysical <br /> Type of Grout. <br /> U 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') _ I <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION }J REPAIR/ADDITION T4_<septic tank or seepage pit permitted if public sewer is �1 <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _r Other <br /> Number of living units: - Z_ Number of bedrooms ��- Lot si e* . 1, 46:c ... <br /> Character of soil to a depth of 3. feet: =�[9 Watertabledepth 9.0 <br /> SEPTIC TANK Type/Mfg C^ Capacity �- No. Coinpakments <br /> PKG. TREATMENT PLT, ❑ Type/Mfg�­;l/' Capacity -Method of Disposal { <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation %- Property Liner' 'µ. <br /> DESTRUCTION r- "r I - <br /> LEACHING. LINE ❑..�/o.'. & Length of lines I Total length/size <br /> FILTER BED ❑ Distance to nearest: ' Well 1 Foundation Property Line <br /> SEEPAGE PITS ~Depth Size a. Number <br /> i <br /> d SUMPS Distance to nearest: Well Foundation 1 Property Line <br /> DISPOSAL PONDS ❑ <br /> F <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 t4dt in the performance of the work for which <br /> this permit is issued, I all mploy persons subject to workman's compensation laws of California." <br /> .�,�.-r <br /> The applicant call a required inspections. Complete drawing on reverse side. rf <br /> Signed X Title: Date: f' /�' <br /> FOR DEPARTMENT JSF-ONLY <br /> Application Accepted by �"` — - Area ❑ Stk 466-6781 <br /> Additional Comments: " " Lodi 369-3621 <br /> Pit or Grout Inspection Date ❑Manteca 823-7104 <br /> d <br /> Final Inspection by Date L7 Tracy 835-6385 <br /> Applicant - Return all copie to: Environmental Health Permit/Services 1601 E, azelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT7.REMITTED RECEIVED BY DATE PERMIT NO. <br /> .. A <br /> INFON, L4� <br /> ir <br /> EH 13-24 REV. 10/82 _ c 10/82 500 <br /> 14-26._ ,� <br />