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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. 7_�- 73/ <br /> Telephone (209) 466-6781 <br /> DATE ISSUED/ 2 <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 the San Joaquin Local Heal�th District. <br /> Job Address_ 9-7-74 j �g �� �Subdivision Name <br /> Owner's Name - Address Phone .-Q f <br /> Contractor's Name e License No. Phone 0 , <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT <br /> ❑ ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ p„ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 /> Domestic/Private ❑Gravel PackTrac <br /> ❑ Y Dia. of Well Casing <br /> ❑ Public ❑ Other ❑ Delta <br /> F-IIrrigationApprox. E] Eastern <br /> [:] Cathodic Protection Depth Specifications <br /> (J Geophysical Depth of Grout Seal <br /> Ej- Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION W (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence -L Commercial Other available within 200 feet.) (J} <br /> Number of living units: -__L Number of bedrooms Lot size <br /> - f <br /> Character of soil to a depth of 3 feet: Water table depth /4 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE �' No. & Length of lines — Total length/size J� <br /> FILTER BED ❑ Distance to nearest: Well Foundation df <br /> Property Line 4Z&-,D { <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS RL Distance to nearest: Well Foundations Property Line S-Z:, <br /> DISPOSAL PONDS ED _ L <br /> I hereby certify that I have prepared this application and that the work wiillll 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 sig ure certifies the following: "I certify that in the performance of the work for which <br /> this permit i sued, I shall employ per s subject to workman's compensation Taws of California." <br /> The applic t call for 1 req i d n fictions. Compl in n reverse side. <br /> Signed Title: Date: <br /> DEPARTMENT USE ONLY <br /> ' <br /> Application Accepted by Area ©a Q+' Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date /,? -g ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health ermit/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 /> �_l 7,3/ <br /> EH 14-26 REV. 10182 10/82 500 <br />