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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT 4 <br /> 1601 E. hAZELTON AVE., STOCKTON, CA PERMIT NO <br /> HE <br /> t1 n Telephone (209) 466-6781 , 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 /> ibed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> descr <br /> and the Rules and fig lations he �3,oa/�in Loc ealth District. <br /> Job Address � / !/f �� Subdivision Name <br /> Owner's Name <br /> Address Phone 6 <br /> Contractor's Name ' <br /> License No. Alf Phone <br /> TYPE OF WELL/PUMP WORK: NEWWELL [] WELL REPLACEMENT DESTRUCTION U W <br /> PUMP INSTALLATION (.] SYSTEMtREPAIR OTHER L_j I <br /> DISTANC£`.TO NEAREST: SEPTIC TANK t SEWER LINES DISPOSAL FLD. PROP. LINE <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (1} <br /> IJ Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> U Domestic/Private E] Gravel Pack Tracy ,� r Dia..of Well Casing <br /> .e <br /> Public [ Other [ Delta Type of Casing <br /> �j Irrigation Approx. [] Eastern Specifications <br /> F—ICath8dic Protection Depth'^^ Depth of Grout Seal <br /> Geophysical Type of Grout <br /> U Other t # Surface Seal Installed by Q \ <br /> ` Repair Work Done G Type of Pump ' -iH.P. State Work Done 1. <br /> Well Destruction 71 Well Diameterl } Sealing Material (top 50') � <br /> Depth # i Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION (N se tic.t nk a seepa e,.pit er, tted if public sewer is <br /> Yee�� �-��Q�c'O/ ble within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> t Number of living units: Number of bedrooms Lot size <br /> Character of sail to a depth of 3 feet: 1 Water table depth <br /> SEPTIC TANK., �!, Type/Mfg "r Capacity /2a O No. compartments <br /> a .`�. Method of Disposal <br /> PKG. TREATMENT PLT. �] Type/MfgCapacity <br /> a -+ <br /> SEWAGE SYSTEM Distance to nearest:: Well FoundationProperty Line <br /> F DESTRUCTION <br />}r LEACHING LINE LJ No..& Lengthoflines Total length/size <br /> FILTER BED Distance.to nearest: Well Foundation I Property Line <br /> SEEPAGE PITS � Depth 1 Size <br /> Number <br /> SUMPS Distance to nearest: Well Foundation. Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that 1 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. which this <br /> Home owner or licensed agent's signature certifies <br /> following: <br /> s to become subjecthat intohwote rkman� compensationerformance of thewlawsfof California." <br /> permit is issued, I shall not emplo�:any person in suchmannera <br /> Contractor's hiring or sub-contracting signature certifies the following:.. f Cali"I certify that in <br /> the performance of the work for whit <br /> this permit is issued, I shall employ persons subject to workman's`compensation laws ofornia." <br /> The applicant must call for all required inspections. Complete drawing nF reverse side. <br /> Signed Title: - Date: 7 <br /> DEPOTMENT USE ONLY <br /> r Area cl Z_— ® Stk 466-6781 <br /> f C Application Accepted by . YO ❑ <br /> Lodi � 369-3621 <br /> f Y Additional'Comments:* .f~ C�'` "ra-teca 823-7104 <br /> Pit or Grout Inspection by Date !� <br /> Final Inspection Date Tracy 835-5385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> C . . DATE PERMIT NO. <br /> FEE ASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY z <br /> INFO <br /> � 10/82 500 <br /> EH 13-24 REV. 10182 P <br />