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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> A1601 L, HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES I 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 /> 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 an .Regal t ns f the San Joaquin.Local Health Distrj,�t, <br /> V ! <br /> Job Addres L vision me <br /> d <br /> Owner s Name Addre � <br /> L � ' C <br /> Contractor's Name- '.,J � License.No, Phone 5j <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ Y DESTRUCTION <br /> PUMP INSTALLATION Fi.,�SYSTEM REPAIR jJ OTHER U <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 <br /> ❑ Industrial U Open Bottom F-1 Manteca Dia. of Well Excavation <br /> jJ Domestic/Private Gravel Pack ❑Tracy Dia, of Well Casing <br /> ❑ Public ❑ Other ❑ Delta Type of Casing <br /> 77, Irrigation Approx. [Eastern Specifications <br /> Cathodic Protection Depth <br /> ❑ Depth of Grout Seal <br /> EJ Geophysical <br /> Type of Grout <br /> U Other Surface Seal Installed by <br /> Repair Work Done K Type of Pump sH.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> i 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 /> l <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line f�` <br /> DESTRUCTION Q <br /> LEACHING LINE U No. l& Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line r� <br /> k tel. <br /> SEEPAGE PITS Cj Depth Size Number ZA <br /> SUMPS LJ Distance to nearest: Well Foundation Property,Line <br /> DISPOSAL PONDS Cj <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 workmant compensation laws of California," <br /> Contractor's h' i,ng or sub-contracting signatur certi 'es the following: "I certify that in the performance of the work for which <br /> this permit i sued, I shall employ per ons bject 'o workman's co ensation laws of California," <br /> Theapplic t t call f all requir in ction Complete g on reverse side, / <br /> Signed X Title: Date: ! <br /> R AR ENT US LY <br /> Application Accepted by Area ❑ Stk 466-6781 <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 alth Permit/Services 501 1. Hazelton Ave., P-0. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> 111 INFO <br /> E 10/82 500 <br /> ' EH 13-24 REV. 10/82 <br /> 14-26 <br />