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c ' <br /> 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 � Subdivision Name <br /> Address 4- <br /> PhoneOwner's Name � ✓ <br /> Contractor's Nammue C ,e .wJ 7,� License No. Phone I L. <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �► <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 U Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑V'Domestic/Private ❑Gravel Pack ❑ Tracy Dia. of Well Casing <br /> ❑ Public ❑ Other ❑ Delta Type of Casing <br /> Irrigation 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 <br /> Repair Work Done ❑ Type of Pump C H.P. / State Work Done t24,_se:.. <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') ,s' <br /> o� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,ADDITION ❑ (No 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 bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table 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 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size 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 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 us all for required i pections. Complete rawin on reverse side. � � <br /> Signed X �itle: Date: <br /> FO PARTMENT USE ONLY <br /> Application Accepted by ., Area 2 - E] Stk 466-6781 <br /> 4 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date ElManteca 823-7104 <br /> Final Inspection by a 3_-�3 ❑ Tracy 835-6385 <br /> Applicant - Return all copie to: Environ ental e th Perm' /Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO -0 Q 3 3 <br /> 4 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />