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APPLICATION FOR PERMIT <br /> �e SAN JOAQU;N 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 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 i <br /> F 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, <br /> Job Address Z„j �/V/ ;5Rcaq�{ . tz Subdivision Name .� <br /> Owner's Name Aw i/ Address _ r�»-to _ Phone <br /> Contractor's Name License,No. 25~r/-3 y� Phone 4W__921197:_Z <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION ❑ - SYSTEM REPAIR OTHER U <br /> k DISTANCE TO NEAREST: SFPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial U Open Bottom ]Manteca Dia, of Well Excavation <br /> L_I Domestic/Private ❑Gravel 'Pack Tracy Dia. of Well Casing <br /> 17 Public D Other ❑ Delta <br /> Type of Casing � <br /> V Irrigation Approx. E]Eastern vt, <br /> Depth Specifications "1 <br /> i �Cathodic Protection Depth of Grout Seal <br /> } Geophysical Type of Grout <br /> ttt U 0ther <br /> Surface Seal Installed by <br /> Repair Work Done D Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50`) <br /> Depth Filler Material (Below 50') O <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION A (No Septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial AW Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3.feet: Water table depth 7—o <br /> SEPTIC TANK Ej Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT- Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM o Distance to nearest: Well Foundation Property Lire <br /> : DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED. Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth :Z r Size �g Number fL <br /> SUMPS Distance to nearest: Wei1/3i/T Foundation 149 Property Line <br /> 3 DISPOSAL PONDS Lt�9't�► <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 workmanS compensation laws of California." <br /> Contractor's hiring or.sob-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 applicant must—call for al equire s ctions. Complete drawl or,, <br /> reverse ide. <br /> Signed XTitle: Date: <br /> ARTMENT USE ONLY <br /> 4 Application Accepted by Area Stk 466-6781. <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date3 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-D. .Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />