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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �Q <br /> 1601 E. NAZELTON AVE., STOCKTON, CA PERMIT NO. 0 -3- (IA-13 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUER DATE ISSUEDr a 3 <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct a�nd/or 11 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 /> i and the Rules and Regulations of the San Joaquin Local Health District. <br />` ,Job Address <br /> Subdivision Name <br /> Owner's Name UAdress Phone <br /> k Contractor's Name License No. Phone <br /> ,-TYPE OF WELL/PUMP WORK. NEW WELL WELL REPLACEMENT 0. DESTRUCTION [_J <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IndustrialU Open Bottom E]Manteca Dia. of Well Excavation /if <br /> Domestic/PrivateGravel Pack (Tracy Dia. of Well Casing <br /> Public G Other. []Delta <br /> Irri ation ♦ Type of Casing <br /> �- 9 — Approx. E] Eastern eci S <br /> Cathodic Protection Depth - Specifications <br /> 1-1 Geophysical Depth of Grout Seal ° <br /> ype orouty-'-rd <br /> U Tf G <br /> Other <br /> Surface Seal Installed,;by <br /> Repair Work Done ❑- Type of Pump"' D H.P. State Workr <br /> Dan <br /> Well Destruction U Well Diameter Sealing Material. (top 50') <br /> �- <br /> Depth Filler Material (Below 501). <br /> AIJ <br /> 77 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0 (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence * Commercial _ Other available within 200 feet.) <br /> Number of living units: Number of,bedrooms 3� Lot size <br /> Character of soil to a depth of,3 feet: _ � �/ - Water table depth _ <br /> SEPTIC TANK [j Type/Mfg `- `-Capacity o.- Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity. Method of Disposal <br /> Septic.•Tank ctimO Distance-=to"nearest: Well Foundation Property Line <br /> _Destr <br /> LEACHING LINE No. &'Length of, _lines Total length/size 70 <br /> FILTER 8E0 Distance to nearest: Well Foundation , Property;Line Q <br /> ,... <br /> SEEPAGE PITS Depth` - Size Number <br /> SUMPS U Distance to,nearest: Well Foundation Property-Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared"this.applica•tion 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 I. 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.appi •ca t must tail f r al r quired-inspections. Complete drawing on reverse side. <br /> Signed X Title; - i <br /> Date: <br /> t DEP NT USE ONLY -" ea-- h .� ❑ <br /> Ap kation Accepted by Area Stk 466-6781 ,! <br /> Additional Comments: Lodi 369-3621 <br /> + Pit or Grout Inspectign by Dade QManteca 823-7104 <br /> Final Inspection by Date EJ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, .Stk., CA 95201 <br /> FEE BASE .AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFO DATE PERMIT N0. <br /> ; -y <br /> EH 13-24 REV.t10/8 �- �j e 10/82 540 <br /> 14-26 `� 40 <br />