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APPLICATION FOR PERMIT <br /> SAN JCAQLiN 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 Subdivision Name <br /> Owner's Name ��/►�j ,7,y"-4r4e_ Address Phone <br /> Contractor's Name i�� /�"4/' License No. -J2,��,"�� Phone 3 �t <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT M DESTRUCTION U <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private Gravel Pack ❑Tracy Dia. of Well Casing <br /> Public ❑ Other [] Delta Type of Casing <br /> �jirrigation Approx. ❑ Eastern <br /> ❑ Cathodic Protection <br /> Depth Specifications <br /> Depth of Grout Seal _ <br /> ❑Geophysical <br /> Type of Grout <br /> ❑Other <br /> Surface Seal Installed by G~ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (tap 50') <br /> Depth Filler Material (Below 50') V' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION V (No septic tank or seepage pit permitted if public sewer is <br /> i available within 200 feet.) <br /> Installation will-serve: Residence Commercial Other <br /> a .. <br /> Number of living units: Number of bedrooms J___.._____. Lot size C <br /> Character of soi3 to a depth of 3'feet: Waterable depth <br /> SEPTIC TANK 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 ❑ <br /> LEACHING LINE No. & Length of lines O - Total len /size <br /> FILTER BEDDistance to nearest: ,Well�7_Foundation Property Line <br /> SEEPAGE PITS Cj Depth Size w, Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Califdrnia:" <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 applicant must call or all require inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Area O Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date [ Manteca 823-7104 <br /> Final Inspection by Date _4-2rf-t­t�'r L Tracy 835-6385 <br /> Applicant - Return all copie . Envirormertal Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 <br />_ FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> ILI- <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />