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APPLICATION FOR PERMIT <br /> SAN JOAQU'IN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT No. � f <br /> Telephone (209) 466-6781 tt i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED.-it- <br /> (Complete <br /> SSUED _r4--�?���3 <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/ <br /> and the Rules and Regulations of the San Joaquin Local Health District, <br /> Job Address Subdivision Name <br /> Owner's Name Address <br /> Phone <br /> Contractor's Name License No.- 3e Y772phone - A <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION U <br /> PUMP INSTALLATION SYSTEM REPAIR LJ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i I <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> LJ Domestic/Private Gravel Pack Tracy Dia, of Well Casing <br /> 17 Public EJ Other Delta <br /> V Irrigation Type of Casing <br /> Approx. Q Eastern <br /> Cathodic Protection by Depth Specifications <br /> L7 Geophysical Depthtof Grout Seal <br /> U Other Type of Grout <br /> a Surface Seal Installed by <br /> Repair Work Done E] Type of Pump �' H.P. State Work Dane <br /> Well Destruction U Well Diameter Sealing Material .(top 501) <br /> Depth t Filler Material`(Below 501) wv <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION RFr-Mo septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial"/ Other <br /> Number of living units__ * Number of b�rooms Lot size <br /> Character of soil to 11 <br /> of 3 feet: _ { _ Water table depth <br /> SEPTIC TANK �• Type/Mfg Capacity Y- No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM <br /> DESTRUCTION Distance to nearest: Well 'Foundation Property Line <br /> � � <br /> LEACHING LINE U� No. & Length of lines Total length/size <br /> FILTER BED Distance to,nearest:A Well [ Foundation Property Line <br /> SEEPAGE PITS [n Depth 12�j` Size ', �._ Number <br /> SUMPS LI Distance-to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that tfie'work will be 'done in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joa'06'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 rthe following::;"I certify that in the performance of the work for which <br /> this permit is issued, I )all employ persons subject to workman's compensation laws of California." <br /> The applicant ca r required inspections. Complete drawing on reverse side. <br /> Signed X - .- Title: 40&J <br /> F DE MENT USE ONLY <br /> Application Accepted by T ;C Area 1' ED Stk 466-6781 <br /> Additional Comments: Lodi 369-3.621 <br /> Pit or Grout Inspection by Date f ��- I <br /> -e, Manteca 823-7104 <br /> Final Inspection by �_jDate r -Tracy 835-6385 <br /> Applicant - Return all,copies to: . Environmental Heal Permit/Services'1601 E. Ha7eltor Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> L46 13-- 1 <br /> EH 14-26 REV. lO/82 W 10182 500 <br />