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APPLICATION FOR.PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1501 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. a <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES I 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 Q <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 Rulesand Regulations of the San ,loaqui Local:. Health Dii <br /> Job Address b iv ion Name <br /> Owner's Name i Address <br /> Phone <br /> Contractor's Name License No. Z Phone -72 <br /> r <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT L] DESTRUCTION U } <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IJ Industrial U Open Bottom D Manteca Dia. of Well Excavation <br /> LJ Domestic/Private F-1 Gravel Pack ❑-Tracy Dia. of Well Casing <br /> .Public F-10ther 0 Delta Type of Casing _ <br /> ,Irrigation Approx. EJ Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> 1-1 Geophysical Type of Grout ` <br /> t <br /> ❑Other Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done Gum <br /> Well Destruction U Well Diameter Sealing Material (top 50') — <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is 'r <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of sail to a depth of.3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENV PLT, [-I Type/Mfg <br /> Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> E <br /> OESTRUCTION U <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Number <br /> 4 Property Line <br /> SUMPS Distance to nearest: Well Foundation <br /> I IJ <br /> DISPOSAL PONDS CI <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 rul_es and regulations of the San Joaquin Local Health District. <br /> Ilit 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 warkmanE 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 /> k The applica m t cal or r qu i pectivns. Complete drawing on e• <br /> Signed X Title: r <br />{ FOR DEPARTMENT USE ONLY Stk 456-6781 <br /> Application Accepted by Area <br /> Additional Comments: - Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by1f Date L Tracy 835-6385 <br /> Environments ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant - Return all copies to: , <br /> FEE BASE MOUNT DUE AMOUNT REMITTED RECEIVED BY DATE <br /> PERMIT NO. <br /> INFO ��%L 7�7 <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 <br /> 14-26 # <br />