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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT ryry <br /> 1601 E. ( 4 <br /> HAZELTONAVE., STOCKTON, CA PERMIT NO, <br /> 6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />• (Complete in Triplicate) <br /> Application is hereby madeito 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 Regula io f th nJoaquin Local Health District. <br /> Job Address �, Subdivision Name <br /> t­�Owner's'Name Address Phone <br /> r <br /> Contractor's Name o_ License No.: L Phone <br /> E - <br /> TYPE OF WELL/PUMP WORK: I� NEW WELL Q WELL REPLACEMENT [].+ .DESTRUCTION Q� <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ ! OTHER U <br /> r _ <br /> -DISTANCE T_O_NEAREST: SEPTIC TANKSEWER LINES _DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONY AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />!' 17 Industrial Open Bottom ❑ Manteca Dia. of Well Excavation <br /> _ LJ <br /> Domestic/Private fi Gavel Pack ❑ Tracy Dia. of Well Casing <br /> { ❑ <br /> Public !'� Other- _�.�❑ Delta }�:.... <br /> Type of Casing # <br /> f "" Li Irrigation !9 Approx. E] Eastern <br /> Specifications <br /> Depth <br /> ? �Cathodic Protection ., <br /> Depth of Grout Seal q <br /> Geophysical <br /> Type of_GrouL s <br /> Other <br /> Surface Seal Installed by <br /> :Repair Work DoneFF" Type'of"Pump' H.P. State`WoFk`Done <br /> $Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth''1 I i Filler Material (Below 50');' <br /> TYPE OF SEPTIC.WORK: NEW INSTALLATION; REPAIR/ADDITION J �(No septic tank or�seepage Rpit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will server Resident e Commercial Other <br />!E Number of living units: Number of bedrooms _ Lot size [) f <br /> Character of soil to a depth of 3 feet: i ._ Water table depth <br /> SEPTIC TANK ,X Type/Mfg C ►, Capacity ��T No. Compartments <br /> PKG. TREATMENT PLT. C]JEType/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM D <br /> I� � Distance to nearest: Well Foundation Property Line . <br /> DESTRUCTION b I h <br /> LEACHING LINE %L if Li r+'-No: & Length of lines } [7 Total length/size CIO <br /> FIL-TE0 BED t, Distance to nearest: Well Foundation Property Line <br /> ,h <br /> r <br /> P SEEPAGE PITS Depth Size Number <br /> r SUMPS ',Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ....-C1 <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'workmant 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 permitl.is issued, I's'hall employ persons subject to workman's compensation laws of California." <br /> i <br /> T appnGrout <br /> 1.1 uire sp tions. .Complete,d wing on revers side. <br /> Signe Title: Date <br /> DE T ENT USE ONLYAd by, Area 7 �J' ❑ StkAs: Lodi 369-3621 <br /> Pcrtion y �, Date Manteca 823-7104 <br /> Final Inspection by Date S' a J L Tracy 835-6385 <br /> Applicant -I 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 p PERMIT NO. <br /> INFO fila. _A Cou <br /> E, 10/82 REV. 10/82 �� 10/82 500 <br /> 14-26 c , <br />