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[e- APPLICATION FOR PERMIT i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT CB l <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781t_ <br /> _ DATE ISSUED 5—I <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 Re ulations of the San Joa u' Local e lth DisttrKt. <br /> Job n Address rvTk, . Subdil ame <br /> Owner's Name Address Phone 3 <br /> Contractor's Nam '�Cicense No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ QESTRUCTION ❑ i <br /> PUMP INSTALLATION SYSTEM REPAIR fl -.OTHER [� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES :DISPOSAL FLO. PROP. LINE, i <br />' FOUNDATION AGRICULTURE WELL -/OTHER WELL PITS/SUMPS <br />{ 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPEChFTCATIONS <br /> 17 Industrial U Open Bottom Manteca Dia. of Well Excavation, <br /> Domestic/Private F-1 Gravel Pack Tracy Dia. of Well Casing _ <br /> Public F-1 Other ❑ Delta i <br /> iJ IrrigationApprox. Eastern Type of Casing <br /> f - <br /> Depth Specifications <br /> Cathodic Protection Depth of Grout Selal <br /> Geophysical <br /> Type of Grout ; <br /> Other <br /> x Surface 5eai Installed by <br />_ Repair Work Done ❑ Type of Pump H.P. 1 State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION:111Mo septic tank or seepage-pit permitted if public'sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _V Commercial Other a+ 'a,' r `•.- ,�:' <br /> Number of living units: Number of bedrooms I ;,—Lot size <br /> Character of soil to a depth of 3 feet: 0A P*-- ( Water table depth r' ' <br /> m_ <br /> SEPTIC TANK Cj Type/Mfg Capacity �"�;�_ No. Compartments I <br /> PKG. TREATMENT PLT. Type/Mfg Capacity f i Method. of Ditposal "! <br /> Distance to nearest: Well Foundation �` r Rroperty Line <br /> LEACHING LINE Fn--No. & Length of lines -' Total length/size <br /> FILTER BED 17 Distance to nearest: Well Foundation Property Line <br /> a �+ <br /> SEEPAGE PITS PR Depth Size 33� Number `? ' ' <br /> SUMPS LI Distance to nearest: Well Foundation Property' Lind <br /> tISPOSAL PONDS El <br /> I hereby certify that I have-prepared this application and that the work will be done in accb_rdance with'tSan Joaquin;county <br /> ordinances, state laws, and rui,es..and-regulations•nfkthe_Sap Joaquin Local Health Districts <br /> Home owner or licensed agb is 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. <br /> Contractor's Kiri r sub-contracting. nature certifies the following: "I certify that,;n' the performance of the work for which <br /> this permit is ed, I shall a e'rsons bject�to,workman`s compensation laws of California." <br /> The app st e ?l fog r`equ' a s' e i -Com 'e" <br /> side. I <br /> r <br /> �Tim e: 3 Dater r <br /> E)ART NT USE ONLY <br /> Application Accepted by' " <br /> �p' Area V i Stk 466-6761 <br /> f Additional Comments: t [] <br /> Lodi 369-3621 <br /> Pit or Grout Inspection by Date -5--:Y7 Manteca 823-7104 <br /> Final Inspection by Date -,c--/ 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 /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY E DATE PERMIT NO. <br /> INFO <br /> ce <br /> EH 13-24 REV. 10/82 ~`= °" 10/82 500 <br /> 14-26 <br />