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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL. HEALTHISTRICT <br /> 1601 E. HAZELTON AVE- STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466.-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Completetin 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 applicati n is macmpliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> and the Rule. T2 t !Jig Sa .doaquin. Local Health District., <br /> Job Address 7—/{ ",, A11. Subdivision Name <br /> Owner's Name 9eyi-7'7;' /;vTds{�yfsr s _ Address Phone <br /> Contractor's- Name C License No. W3%e-v^9/ Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 <br /> ti. <br /> DISTANCE TO NEAREST: SEPTIC TANK �'' ''s SEWER t'INES �% �x DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 14 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial [j Open Bottom []Manteca Dia. of Well Excavation <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing <br /> ❑ Public ❑Other [] Delta TypV <br /> Irrigation Spec of Casing <br /> g � Approx. ❑ Eastern Specifications <br /> ❑ Cathodic Protection Depth Depth of Grout Seal <br /> ❑Geophysical <br /> Type of Grout <br /> Other <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Dane <br /> + Well Destruction ❑ Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below -50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ) (No septic tank or seepage pit permitted if public sewer is <br /> 1 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 <br /> SEPTIC TANK ❑ 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 A-' Foundation Property Line /f' <br /> SEEPAGE PITS ❑ Depth Size Number <br /> E SUMPS' Distance to nearest: Well Foundation Property Line v3X` <br /> { DISPOSAL PONDS ❑ i <br /> 1 <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'manher"as to become subject to workmant compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the •following:,"I certify that 1n,the performance of the work for which <br /> this permit is issued, I shall employ persons subject to,workman's compensation lawstof-CwI'ifornia." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> G flFj�RTMENT USE ONLY <br /> Application Accepted by Area 7 3� ❑ Stk 466-67$1 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date ❑ Manteca 823-7104 <br /> Final Inspection by -Date � "d'T L Tracy 836-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.p, Bax 2009, Stk., CA 95201 <br /> J <br /> FEE BASE AMOUNTt. DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> . " . . <br /> FH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br /> k <br />