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APPLICATION FOR PEP;,;;T <br /> SAN JOAQLitt LOCAL 'nEALTH DISTRICT <br /> � � 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ars <br /> 4� Telephone (209) 466-6781 <br /> 13 DATE ISSUED —X4 <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 <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 bdivision Name <br /> Owner's Name Address L7 <br /> Contractor's Name License No. 11 —T Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR 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 <br /> I� Industrial U Open Bottom [] Manteca Dia. of Well Excavation <br /> Domestic/Private F-1 Gravel Pack f—ITracy Dia. of Well Casing <br /> �] Public F-1 Other Delta <br /> Type of Casing <br /> Irrigation Approx. [] Eastern <br /> Cathodic Protection Depth Specifications <br /> Depth of Grout Seal <br /> ❑Geophysical <br /> Type of Grout <br /> F-1 Other <br /> Surface Seal Installed by <br /> Repair Work Done Ej Type of Pump H.P. t State Work Done 1, -4 /2ijd-4; <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 71 (No septic tank or seepage pit permitted if public sewer is pJv� <br /> available within 200 feet.) <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 a <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. _J Type/Mfg Capacity Method of Disposal N <br /> SEWAGE SYSTEM 11---� Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION U <br /> LEACHING LINE {_J No. & Length of lines Total length/size <br /> FILTER BED I—] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS [j Depth Size Number <br /> SUMPS LJ 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 q 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 /> The applicant mus call for all required inspections. Complete dr g on reverse side. <br /> Signed Xo <br /> r. '..r.__ Title: 1fi'D„ i.M-ti•- Date: <br /> P <br /> Application Accepted by �' Area E] Stk 466-6781 <br /> Additional Comments: E] Lodi 369-3621 <br /> Pit or Grout Inspection Date L�] Manteca 823-7104 <br /> Final Inspection by Date 2 ❑ 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 DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 — 10/82 500 <br /> 14-26 31-7 <br />