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v <br /> APPLICATION FOR PERMIT <br /> SAN JOAQU'iN LOCAL HEALTH DISTRICT I_ <br /> 1 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> I Telephone (209) q66-6781 Y <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED _ DATE ]SSUEO d3 <br /> (Complete in Triplicate) <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 of the S n Joaquin Local health District. <br /> lab Address— <br /> C) rj Q/Y\ SfC>Ck Subdivision Name- <br /> Owner's Name Address _ <br /> Phone <br /> Contractor's Name 7C e No. ZL C) Phone d OA <br /> TYPE OF <br /> WELL/PUMP WORK: NEW WELL L WELL REPLACEMENT [] DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER L <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINEp�y <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> Domestic/Private V,Gravel Pack Tracy Dia. of Well Casing <br /> Public L Other Delta <br /> Li <br /> Irrigation Type of Casing 9 Approx. L Eastern <br /> E]Cathodic Protection Depth Specifications <br /> 17 Geophysical <br /> Depth of Grout Seal <br /> L DLher <br /> Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump State Work Done <br /> Well Destruction L WelI Diameter /$ Sealing Material •(top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is � <br /> Installation will serve: Residence _ Commercial Other Ci <br /> available within 200 feet.) <br /> Number of living units: Number of bedrooms Lot size ` <br /> Character of soil to a depth of 3 feet: _ Water table depth <br /> SEPTIC TANK Ej Type/Mfg 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 ❑ p <br /> LEACHING LINE U No. & Length of lines f Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS L Depth Size Number !!!!! <br /> SUMPS L Distance to nearest: Well Foundation Property Line I <br /> DISPOSAL PONDS ❑ k <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county I <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." <br /> The applica must cal for all r ired inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> F EPARTMENT US LY <br /> Application Accepted b Area 0 Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by jAft�. Date 7 L Tracy 835-6385 <br /> �A licant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f. FEE BASE AMOUNT DOE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> EH 13-24 REV. 10/82 (} 10/82 500 " <br /> 14-26 <br />