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-� APPLICATION FOR PERMIT <br /> b # <br /> SAN JOAQLir! LOCAL HEALTH D-1-STRICT <br /> 1601 F. HAZELTON AVE., STOCKTON, CA PERMIT NO. 3` �a 7� <br /> Telephone (209) 466-6781 1 <br /> DATE 155UE0 7 /� , <br /> PERMIT EXPIRES 1 YEAR-FROM DATE ISSUED <br /> (Complete.in Triplicate). <br /> Application' is hereby made to the San Joaquin Locel 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 o the San o�quin Ldcal Health District. <br /> Job Address Subdivision Name <br /> Owner's Nameddress Phone <br /> Contractor's Name License No. Phone <br /> f Ir <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR 0— OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ° PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER 1d ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial U Open�Bottom Manteca Dia, of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Dia, of Well Casing <br /> L�. <br /> Public [—t Other Delta <br /> f Type .of Casing j <br /> Lj Irrigation Approx. Eastern <br /> 71 Specifications <br /> Cathodic Protection Depth S p <br /> I� <br /> Depth of Grout Seal <br /> Geophysical <br /> IJ Other Type of Grout I <br /> v, 'Surfaee'Seal InstaT�led-by <br /> . epair Work Done H,P. State Work-Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth { Filler Material (Below 50') <br /> �• i•m nnm• nlrnir.. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDI=N <br /> _ � LI 1� {No septic tank or seepage pit permitted if public sewer is i <br /> C' available within 200 feet.) <br /> Installation will serve: Residence x Commercial y. Other . <br /> Number of living units: .Number of bedrooms �� Lot.size B�r <br /> Character of soil to a depth of 3 feet: Water table depth D <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. (Type/Mfg Capacity Method of Dispo,�.a� <br /> SEWAGE SYSTEM ',Distance .to nearest: Well Foundation Property Line j <br /> DESTRUCTION <br /> LEACHING LINE' No. & Len'gth of lines Total length/size Q <br /> FILTER BED :Distance,to nearest: "Well " Foundation . Property Line <br /> SEEPAGE PITS 'Depthsize Number <br /> SUMPS Distance o nearest: Well .Foundation Property Line <br /> DISPOSAL PONDS CI ; <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 followings "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 became 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 appljca mu cal for required inspe ions. Complete dr wing on reverse side. <br /> Signed X Title: � �o Vit. .F Date: <br /> D ARTM USE ONLY <br /> Application Accepted b .-Area /i Q Stk 466-67 <br /> Additional Comments: i �y_. _ Lodi 369-3 21 <br /> Pit or Grout Inspection by �i � Date �� Manteca 823-1104 <br /> Final Inspection by ��a✓f, L ,� �� Date s L Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 16dl E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. J <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br /> 7 <br />