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------------- --_-- <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED 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 and Regulations of the San Joaquin Local health District. <br /> Job Address—aSubdivision Name <br /> Owner's Name T�{a,"L}� Address 3s1 <br /> -5 ckxm <br /> Phone <br /> Contractor's Name License No, phone .�� ,5 <br /> TYPE OF WELL/PUMP WORK: NEW WELLWELL REPLACEMENT <br /> �I ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK _ CA2p SEWER LINES DISPOSAL FLO. ACO — PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑Open Bottom Manteca Dia, of Well Excavation <br /> Domestic/Private Gravel Pack ❑ Tracy Dia, of Well Casing <br /> ❑ Public ❑Other ❑ Delta <br /> (J IrrigationType of Casing <br /> Approx. ❑ Eastern <br /> ❑Cathodic Protection Depth Specifications <br /> ❑Geophysical Depth of Grout Seal 5O' <br /> LI Other Type of Grout <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 50') <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (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 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 /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number _ <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Taws of California." <br /> The appl' t must call for all required inspections�PARTMCNIVUSE <br /> Complete d awing on reverse side. <br /> Signed Title: Date: �a _ <br /> DR ONLY <br /> Application Accepted byArea 3 ❑ Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by p., Date Manteca 823-7104 <br /> Final inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: E vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> :� 3 <br /> EH 13-24 REV. 10/82 <br /> 14-26 1 1 1 10/82 500 <br />