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` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <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 Regulations of the San Joaquin Local Health District. <br /> Job Address 0 � � cSubdivision Name i <br /> I <br /> Owner's Name Address Phone --+ <br /> Contractor's Name SE C License No. llykY6 Phone 461 <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION i <br /> PUMP INSTALLATION E] SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial Open Bottom Manteca Dia. of Well Excavation <br /> !J Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing 1 <br /> 17 Public Other ❑ Delta <br /> Type of Casing <br /> U Irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal w <br /> Geophysical Type of Grout Q <br /> Other <br /> Surface Seal Installed by <br /> Repair Work. Done FJ Type of Pump H.P. State Work Done � y <br /> Well Destruction Well Diameter 46 <br /> rf Cao Sealing Material (top 501) <br /> Depth r]aA Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> C <br /> Installation will serve: Residence _ Commercial _ Other available within 200 feet.) Z <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 /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION Q <br /> ,r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS CI Depth Size Number 1 <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> irni.r i i nirrrrrrir <br /> murnrr <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." <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 /> The applica t st cap11 for al requ'red inspections. Complete drawing on reverse side. /y <br /> Signed X r Atm Title: <br /> FOR A TMENT USE ONLY <br /> Application Accepted by Area Stk 466-67Bi <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout inspection DateManteca 823-7104 <br /> Final Inspection by } Ago,_/ Date 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 BASEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> ov <br /> A 1019- <br /> EN <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />