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APPLICATION FOR PERMIT _ <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT 1` <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. f <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) i <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, I <br /> Job Address &A Cz Subdivision Name <br /> Owner's Name <br /> Address.2/3 7 one Z - <br /> Nr� ense No. Phone <br /> Contractor's <br /> } <br /> i <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR L7 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 w <br /> Industrial LjOpen Bottom F-1 Manteca Dia, of Well Excavation <br /> U Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Public Other Delta Type of Casing <br /> Lj Irrigation Approx. ❑ Eastern Specifications <br /> r-ICathodic Protection Depth Depth of Grout Seal <br /> 1 <br /> Geophysical Type of Grout W <br /> Other Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done V <br /> 4 Well Destruction ❑ Well Diameter Sealing Material (top 50') - <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is _Q1 <br /> -- available within 200 feet.) 0 <br /> Installation will serve: Residence _ Commercial Other <br /> Number of living units: Number of bedrooms Lot size 3 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 01 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 U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property tine <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I <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 /> 1 The applican ust call for all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: Date: <br /> R DEPARTME USE ON LP <br /> Stk 466-6781 <br /> Application Accepted by Area <br /> Lodi 369-3621 <br /> Additional Comments: <br /> Pit or Grout Inspection by <br /> Date Manteca 823-7104 <br /> I Date r L7 Tracy 835-6385 <br /> k Final Inspection by <br /> Applicant - Return all copies to: Environmental Health Permit/ RECEIVED 1601 E. Hazelton Ave., P,O. Bax 2009, St k., CA 95201 <br /> v PERMIT NO, <br /> FEE BASE --.AMOUNT DUE AMOUNT REMITTED RECEIVED BY DAT <br /> PE MI (O, <br /> INFO b d(} AV <br /> 10/82 500 <br /> EH 13-24 REV. 10182 <br /> _.� 14-26 <br /> r. y <br />