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APPLICATION FOR,PERvIT <br /> Lo <br /> SAN JOAQJiN 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 OATS ISSUEG <br /> i <br /> - (Complete in Triplicate) <br /> s 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 S n Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> {I and the Rules nd Re ulat s of t e San Joaquin L c H lth District. <br /> ! Job Address ouSubdivision Name <br /> Owner's Name d ress phone <br /> Contractor's Name Phone <br /> i TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> I PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ 1q CA 00 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOJNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENQ,ED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> eInt,,al, Ope ttom Man Dia. of Well Excavation <br /> Mo c/Pivate U 77 <br /> ravel Pack ❑ racy Dia, of Well Casing <br /> ❑ <br /> Public OtVr Delta Type of Casing <br /> L Irrigation Approx. ❑ Eastern <br /> Cathodic Protection Depth Specifications <br /> Depth of Grout5 1 <br /> Geophysical Type of Grout Q . <br /> ❑Other <br /> Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done \. <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> r Depth Filler Material (Below 50') Q, <br /> 1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION J (No septic tank or seepage pit permitted if public sewer is O <br /> available within 200 feet.) Q <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 SYSTEMDistance to nearest: ' Well Foundation Property Line <br /> DESTRUCTION ❑ <br /> LEACHING LINE ❑ No. & Length of-lines Total length/size <br /> FILTER SED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS• • F-1 R Depth 'y. Size Number <br /> SUMPS *'Distance to nearest: Well Foundation Property Line <br />} <br /> DISPOSAL-PONDS <br /> f <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 sh"nemployy person in such manner as tobecome subject to workmans compensation Paws of California." <br /> Contractor's hiring osignature certifies the following: "I certify that in the performance of the work for which <br /> this permit is is ed, er ns subject to workmans o sation laws of California." <br /> The applican nsp tions. Complete a n re <br /> Signed X Title: 4667LDate <br /> F j DEP TMENT USE ONLY <br /> Application Accepted by Area Stk 466- 81 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date— 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 GATE PERMIT NO. <br /> INFO <br /> sa-li _Z 4S <br /> i. EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />