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APPLICATION FOR PERMIT er <br /> I SAN JOAQUir! LOCAL HEALTH DISTRICT <br /> r 1601 E. HAZELTON AVE,, STOCKTON, CA <br />{ Telephone (209)'466-6781 PERMIT NO. X55 <br /> I PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED 5 7 <br /> {Complete in Triplicate) t <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 <br /> and the Rules and ulat ns of t e San oa uin Local Health D, k herein <br /> Job Address q ict, for well/pump <br /> Owner's Name ' u�division Name <br /> Address <br /> Contractor's Nam gel ! Phone <br /> License No. <br /> phone <br />[ TYPE OF WELL/PUMP WORK: ,.�NE41 WELL <br /> ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TANK ❑ OTNER <br /> SEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL PROP, LINE <br /> OTHER WELL �4 PITS/SUMPS <br /> INTENDED USE TY+SE_ �F WELL <br /> PR <br /> [J Industrial OBLEM AREA CONSTRUCTION SPECIFICATIRNS <br /> Open Bottom Manteca Dia. of Well Excavation <br /> LJ0omestic/Private ; <br /> ❑Gravel Pack ❑ Tracy <br /> Public Dia. of Well Casing <br /> ❑ ❑Other ❑ 0elta <br /> Irrigation OApprbx. Eastern <br /> Type of Casing r <br /> � <br /> ❑Cathodic Protection Depth Specifications <br /> ❑Geophysical " Depth of Grout Seal <br /> ❑Other Type of Grout J <br /> 'Repair Work Done T Surface Seal Installed by•r <br /> ❑ Type of Pump H.P, <br /> Well Destruction FJ Well Work Done <br /> Well Diameter Cf� <br /> Sealing Material (top 50') } <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION — <br /> �1�REPAIR/,ADDITION ❑ (No septic tank or seepage'pit permitted if public sewer is <br /> Installation will serve: Residence _v Commercial _ Other ¢ available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Lot size <br /> SEPTIC TANK Type/Mfg '.'Water table depth o* 1 <br /> PKG. TREATMENT PLT. Type/Mfg Capacity No. Compartments <br /> ❑ Capacity <br /> SEWAGE SYSTEM Distance to nearest: Well .,�0 ----.-. Method 0.-f4 Disposal -- -- <br /> DESTRUCTION ❑ Foundation Property Line <br /> LEACHING LINE No. & Length of lines <br /> FILTER BED — ' 0* Total length/size <br /> Distance to nearest: Wel 7' <br /> - Foundation <br /> Property Line <br /> SEEPAGE PITS Depth Z Size <br /> SUMPS —~'— G , Number <br /> Distance to nearest: WeT1 00 Foundation <br /> DISP05AL PONDS ❑� Property Line ,. <br /> -s <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 ofthe San Joaquin' Local Health District. ,h <br /> Home owner or licensed agent's signature certifies the following- <br /> permit is issued, I shall not employ an "I certify that in the performance of the work for which this <br /> Contractor's hiring or sub-contracting employn y person in such manner as to become subject,.to workman§ compensation laws of California." <br /> this permi is issued I shall a ploy rsnnsure subjectitoes the workman'slowing, "I ccompensationrlaws ofat in the Californiaerformance of the work for which <br /> The app t r ections. Complete drawing on reverse side. <br /> Signed ,r <br /> Title: c Date: 7 — �.7., <br /> Application Accep ed by EPARTMENT USE 0 Y <br /> Area r' �y ❑ Stk 4.66-6781 <br /> Additional Comments: —-7 — <br /> Pit or Grout Inspection by - odi 369-3621 <br /> Date s �� Manteca 823-7104 <br /> Final Inspection by k <br /> Date Tracy 835-6385 <br /> Applicant - Return a17 co s to: Environmental Health Permit/Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> 1 EH 11-2-4- E.qV. 10/82 <br /> y <br /> IR 26 10/82 500 ! <br /> ' t <br />