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APPLICATION FOR PERMIT <br /> SAN JOAQL2, LOCAL HEALTH, DISTRICT <br /> 1601 E. HAZELTON AVE„ STOCKTON, CA PERMIT NO. ^. <br /> Telephone (209) 466-6781. V11J ; <br /> DATE ISSUED ' <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. 1662 for well/pump s <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address VJ Subdivision Name <br /> Owner's Name Address Phone <br /> Contractor's Name -u— License No. <br /> 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 /> F Industrial U open Bottom Manteca Dia. of Well Excavation <br /> ,Lf <br /> Domestic/Private � � Gravel Pack _ _ ,Tracy � 4 Dia. o_f_Well_Casing_ <br /> Public F 10ther Delta Typo of Casing <br /> V Irrigation { Approx. ❑ Eastern Specifications <br /> Cathodic Protection Depth <br /> ❑ Depth of Grout Seal ; <br /> 17 Geophysical Type of Grout ; <br /> Other <br /> Surface Seal Installed by <br /> Repair Work Done-E] Type of Pump { H.P. State Work Done 1 <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ A <br /> Depth Filler Material (Below 50') <br /> s <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is } " <br /> l ; 1. ' -available within 200 feet.) Y <br /> Installation .will serve: Re idence _ Commercial Other 4q y" <br /> Number of living units: Number of bedrooms Lot size f ; <br /> Character of soil to a depth of 3 feet: � t..� <br /> t Water table depth ' <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg i � ­Cai�y Method of Disposalpac •fir-. <br /> SEWAGE SYSTEM Distance to nearest: wil0 <br /> u dation Property Line <br /> DESTRUCTION '. t <br /> LEACHING LINE a " No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation ; Property L}ine <br /> SEEPAGE PITS Depth Size . Number ) t <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> s <br /> a � <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.ithe 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 /> t ermit is issued, I shall employ persons subject to workman's compensation laws of California." i <br /> The apple u t��,��qLd �inpect�ion;, Complete wing on rever side. 3/ 2 <br /> Sian � Title: Date: <br /> C-• FOR <br /> ?OLPAE7TK& T USE ONLY <br /> Application Accepted by Area Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspectio Rate i LL] Manteca 823-7104 F <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all cope o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5t k., CR 95201 <br /> FEE BASE AMO DUE AMOUNT REMITTED RECEIVED BY ! DATE MIT N0. <br /> .PER ' <br /> INFO � � aE . e <br /> . . ` " . <br /> 10/82.500 - <br /> - 1D 82 <br /> EH 1324 REV.: / <br /> z <br /> 14-26 � <br />