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if APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT 4,' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT 40. LF 7 <br /> Telephone (209) 466-6781 - <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUEDI <br /> (Cemplete,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 the San Joaquin Loca Health District. <br /> Job Address Subdivision Name <br /> Owner's Nam "f' Address Phone <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM-REPAIR-� �0T+1LR--U <br /> DISTANCE TO NEAREST: SEPTIC TANK _� � r SEWER LINES DISPOSAL FLO, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL r OTHER:WELG_:? PITS/SUMPS % <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECI;fICATIONS k <br /> 1 Industrial a <br /> .�) [J Open Bottom � Manteca ; Dia.."of'Well�'Excavat ion <br /> Domestic/Private Gravel Pack Tracy t, Dia�.•� of Well Casing « "� # <br /> L <br /> Public� Other Delta r Ty-pe of Casing r '; <br /> Lj Irrigation 4g/p?f Approx. Eastern S,i= <br /> Cathodic Protection - Depth '_ 7i; Specifications _- s' <br /> Geophysical Depth of Grout Seal r i ~ <br /> ❑ <br /> Other, Type of Grout &A4,e ! <br /> Surface Seal Installed by , oQ <br /> Repair Work Done ❑ Type of Pump HA' State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Fill er Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION [J (No septic tank or seepage pit permitted if public sewer is " <br /> Installation will serve: Residence Comnerc'ial 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: x Water table depth <br /> l^+ <br /> SEPTIC TANK Type/Mfg ' Capacity "N0. Compartments <br /> PKG. TREATMENT PLT. E] Type/Mfg r Capacity Method of Disposal <br /> s <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property fine <br /> DESTRUCTION ❑ �' i <br /> LEACHING LINE U No. & Length of lin`es'. Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line ' <br /> _.9 <br /> SEEPAGE PITS F-1 Depth Size Number ` i! <br /> SUMPS Distance to nearest: Well Foundation Property Line T. <br /> DISPOSAL PONDS 1 <br /> - f <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wifh San Joaquin county, <br /> ­QrdJ,nances,_sSate laws,;and_rules-and_regulati•ons-of,,the,San_Joaqu in Local Health District. <br /> Home owner or licensed agent's signature certifies the following~ ,I cerflfy"fhat in fhe`per o`rmance df'the work for wti'chzfFiis""" � <br /> permit is issued, I shall not employ any person in suchmanner as,,to,hecome subject;to workman~ compensat'i'on,.-Laws of California," t <br /> Contractor's hiring or sub-contracting signature certifies the fol'16w5ng: "I c6ri fy that in the'pe'rformanie of-the work for which N p <br /> this permit is issued, I shall employ persons subject to workman's compensation. Taws.of California." <br /> The applicant mus 1 0r i Com lete drawin n reverse side. <br /> Signed X Title: Date: <br /> R DEPARTMENT US NLY <br /> Application epted by V`� Area ���� Stk 465-6781 <br /> �I <br /> Additional Corrnnents: ,/ Lodi 369-36210/ ' <br /> t Pit or Grout Inspection by Date 3` U Manteca 823-7104 <br /> Final Inspection by Date L Tracy. 835-6385 c" ;1: <br /> Applicant - Return all copies to: . Environmental ealth Permit/Services 1601 E. Haze�figAl3vr-', P.O. Box 2009, Stk., CA 95201 <br /> i <br /> a <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 4. EH 13-24 REV. 10/82 z9 to/az 500 <br /> 11 <br /> 14-26 <br /> 44 <br />