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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 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 Regulations of e San Joaquin Local Health.District. <br /> Job Address O Subdivision Name <br /> Owner's Name Q Address Z , Phone <br /> Contractor's Name LipAnA No. �� Phone <br /> TYPE OF WELL/PUMP WORK: NEW WEtL�, WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION ' SYSTEM REPAIR LJ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> u Domestic/Private Gravel Pack F-1 Tracy Dia. of Well Casing <br /> D.Publ F-1 Other Delta Type of Casing <br /> V Irrigation Approx. LJ Eastern Specifications <br /> [ <br /> Cathodic Protection Depth � _ Depth of Grout Seal <br /> Geophysical } ! (M <br /> l y � Type of Grout „{ <br /> U,Othert , Surface Seal Installed by <br /> Repair Work Done E] Type of Pump�5�M.P. state Work Done <br /> K �t <br /> Well Destruction U Well Diameter _ Sealing Material (top 50') <br /> l ., --* Depth Filler Material (Below 50') ' <br /> TYPE OF SEPTIC'WORK: NEW INSTALLATION L1 REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> i q available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> a <br /> Number ofIIiVing units: Number of bedrooms Lot size <br /> Character of soil to a depth of�3 feet: Water table depth <br /> 0r Type/Mfg Capacity No. Eompartments �f} <br /> SEPTIC TANK _ <br /> ,PKG. TREATMENT PLT. �. Type/Mfg Capacity' _ 1 Method of Disposal O <br /> .SEWAGE SYSTEM �--I Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION L_d <br /> 1 <br /> LEACHING LINE U No. & Length of lines Total length/size � ,' <br /> FILTER BED Distance to nearest: Well Foundation Property Line .f <br /> SEEPAGE PITS Depth Size Number a t <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line `t <br /> DISPOSAL PONDS <br /> I hereby certify that 1 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 CaIifprnia." <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 t ust call r A re ' td pections. Complete drawin.Wn reverse <br /> Signed X <br /> Title: 1//�t!/� Date' <br /> FW DEP MENT USE ONLY 466-6781 <br /> Application Accepted by Area 02, S t k <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date 0 Manteca 823-7104 l <br /> Final Inspection by Date l� 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 /> Ilf FEE ASE AM NT DUE AMOUNTREMITTED IRECEIVED BY E 'DATE J p30 <br /> INFO ; <br /> AA C�C L + p 10182 500 <br /> EH 13-24 REV. 10/82 l0 l <br /> 14-26 M <br />