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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> � <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {]ATE ISSUED <br /> 4 <br /> �::.:((fomplete 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 andula i f the San Joaquin Local Health District. �7 <br /> Job Address �r Subdivision Name 2�k(S'O.-Q r <br /> Owner's Name j�4— /��q{/< Address �q p k $y­ Phone <br /> Contractor's Name .04 License No. Z Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 /> U Domestic/Private F] Gravel Pack Tracy Dia. of Well Casing <br /> Public Fj Other Delta Type of Casing <br /> F�llrrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical <br /> Type of Grout <br /> LJ Other <br /> Surface Seal Installed by 1" <br /> Repair Work Done 0 Type of Pump H.P. State Work Done r <br /> Well Destruction ❑ Well'Diameter Sealing Material (top 50') !' _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepageipit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> G <br /> Number of living units: Number of bedrooms" L'nt size Ila <br /> Character of soil to a depth of 3 feet: " Water table depth <br /> SEPTIC TANK Type/Mfg /� P,J, Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well X50 FoundationProperty Line �p �7 ' <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"- <br /> SUMPS f�yl Distance to nearest: Well !p 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 allequi d inspections. Complete drawing on reverse side. <br /> Signed X ___ Title: Date: <br /> R D TMENT USE ONLY <br /> Application Accepted by AP/ 677Area 6 ❑ Stk 466-6781 <br /> Additional Comments: El Lodi 369-3621 <br /> Pit or Grout Inspection by Date L7 Manteca 823-7104 <br /> Final Inspection by Date ❑ 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 <br />