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s <br /> S <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE_ STOCKTON, CA PERMIT NO. <br /> Telephone (204) 466-6781 <br /> DATE ISSUED '7--{S-2c� <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 th San Jo uin Local health District. <br /> Job Address � V Subdivision Name <br /> Owner's Name ,!r Address " Phone �1d 7 <br /> Contractor's NameLicense No. � � �� Phonef-Y Z 7 <br /> I - - <br /> Lk <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMW .❑ DESTRUCTION ❑ rI <br /> PUMP INSTALLATION SYSTEM REPAIR 1-171 "OTHER ❑ v <br /> DISTANCE TO NEAREST: SEPT.IC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom Manteca Dia. of Well Excavation <br /> ISI Domestic/Private ❑ Gr vel Pack Tracy Dia of Well Casing <br /> Public ❑ Other ❑ Delta Type of Casing <br /> LjIrrigation Approx. Eastern <br /> Depth Specifications <br /> ❑Cathodic Protection Depth of Grout Seal <br /> Geophysical <br /> Type of Grout <br /> ❑Other ~1 Surface Seal Installed by ,r <br /> Repair Work Done [4 Type of Pump _ H.P. 3 State Work Done �1i f�JA.[fJ'. •C �J <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') _ W <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 /> 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 [J Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. D Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ <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 k� <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 laws of California." <br /> The applicant must call for all required inspections. Complete drawing on rev se side. <br /> Signed X Title: Date: <br /> D P MENT USE ONLY <br /> Appl cation Accepted by Area Stk fib=67 <br /> Additional Comments: ❑ Lodi <br /> Pit or Grout Inspection by Dt Manteca 823-7104 <br /> Final Inspection by f ❑ Tracy835-6385 <br /> Applicant - Return al es 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 <br /> INFO <br /> EH 13-24 RFV. 10/82 10/82 500 <br /> 14-26 <br /> t <br />