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APPLICATION FOR PERMIT s' <br /> SAN JOAQUIN LOCAL HEALTH, DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. S <br /> Telephone (209)466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE I550Ep DATE ISSUED <br /> (Complete in Triplicate) 3 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> 4", <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 San Joaquin Local Health District. <br /> Job Address tSubdivision Name <br /> Owner's Name Address & Phone <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT (� DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK I QO� SEWER LINES DISPOSAL FLD. Q(;+ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial Open Bottom <br /> U P ❑Manteca Dia, of Well Excavation <br /> Oamestic/Private T<ravel Pack DKracy Dia, of Well Casing <br /> 0 Public �J Other Delta <br /> L} IrrigationType of Casing <br /> Approx. � Eastern <br /> Cathodic Protection Depth Specifications <br /> Depth of Grout Seal <br /> Geophysical � <br /> U Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P, State Work Done <br /> ell Destruction Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Lf (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence _ Commercial _ Other 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 /> Distance to nearest: Well _ Foundation Property Line <br /> LEACHING LINE Lj No. &.Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well . Foundation Property Line <br /> SEEPAGE PITS Cj Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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." i <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 /> f The appiiWanust call,for a ed inspections Complet draw' n r ve se side, <br /> Signed X itle: Date: (� <br /> PARTME USE LY ,� (/� <br /> Application Accep by �./ Are �� Stk 466-6781" j <br /> Additional Comments_ E] Lodi 369-3621 <br /> Pit or Grout Inspection by Date ❑ Manteca 823-7104 <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 £: Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT Np. <br /> INFO <br /> EH 13-24 REV. 10/82 �C_ <br /> 14-26 �S 10/82 '500 j <br />