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APPLICATION FOR PERM:- <br /> SAN <br /> ERM:iSA.N JOAN,;N LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTCN, CA PERMIT N0. <br /> Telephone (209) 456-6781 DATE ISSUED (//o { 1 <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 I; <br /> and the Rules and Regul s of the San Joaquin Local Health District. <br /> .lob Address Subdivision Name <br /> Owner's Nameetyed; 0, / >� Address Phone <br /> Contractor's Name-Z>1, e�- License No. �� � Phone ^` <br /> NA�h <br /> � <br /> TYPE OF WELL/PUMP WORK: NEW WELL Q WELL REPLACEMENT DESTRUCTION W ; <br /> PUMP INSTALLATION r7 SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNCATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> I� Industrial U Open Bottom 71 Manteca Dia. of Well Excavation <br /> {_} Oomestic/Private Gravel Pack E] Tracy Dia, of Well Casing <br /> Public CJ Other Delta <br /> Type of Casing � <br /> LjIrrigation Approx. Eastern <br /> ❑ Cathodic Protection Depth Specifications <br /> 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 Done <br /> Well Destruction _J 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 /> 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 near t: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> r <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS U 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 al or 1 re red inspections. Complete drawing on reverse side. <br /> Signed x Title: Date: 6— _ <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by - Area _ _ - Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by <br /> Date �� ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: E v ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201 <br /> FEE JASE AMOUNT D AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO l � � © �C— - <br /> EH 13-24 REV. 10/82 n 10/82 500 E <br /> 14-26 {1� <br />