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•l APPLICATION FOR PERMIT ° <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. q ,� <br /> Telephone (209) 466-6781 / 7� <br /> DATE ISSUED [ Lj <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 1`heykan Joaquin Local Health District. <br /> Job Address S S , Subdivision Name <br /> Owner's Name t 'j, C 'j Address <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION F-] SYSTEM REPAIR L�] OTHER ❑ rA <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS W <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> II J Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation <br /> IJ Domestic/Private ❑Gravel Pack �' Tracy Dia. of Well Casing -" <br /> L:] Public F-1 Other Delta <br /> Irrigation Type of Casing <br /> V 9 Approx. EJ Eastern n <br /> Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal . <br /> Type of Grout <br /> U Other <br /> Surface Seal Installed by <br /> Repair Work Done El Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter s Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/,4DDITION X1 (No septic tank or seepage pit permitted if public sewer is <br /> lTy <br /> available within 200 feet.) <br /> Installation will serve: Residence >- Commercial _ Other ry y <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 Q Type/Mfg Capacity No. Compartments 1 <br /> KG. TREATMENT PLT. F-1 Type/Mfg Capacity Method of Disposal 1 <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE E21 No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well ;Foundation Property Line <br /> SEEPAGE PITSDepth Size Number <br /> SUMPS �� Distance to nearest: Well Foundation Property Line (1 <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 workmank 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 sb bject to workman's compensation laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> 1 '�.�' <br /> Signed X � � Title: Date: 03 <br /> R' 1jARTM N USE,ONLY <br /> Application Accepted by �,,�� �. Area0 K1,10 <br /> Stk 466-6781 <br /> Additional Comments: F-1 Lodi 369-3621 <br /> Pit or Grout Inspection by Date ❑ Manteca 823-7104 <br /> Final Inspection by (1 9� � Date _117 p --�S Ej Tracy 835-6385 <br /> Applicant - Re urn all ces to: Envir m nt Health PeXmit4ervices 1601 E. Ha el on A e P. Box 2 9, Stk., CA 95201 <br /> FEE , ASE AMOUNT DUE AMOUNT REMITTE RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />