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f .. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQL'iN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA — 1 <br /> Telephone (209) 466-6781 PERMIT N0. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED <br /> (Complete in Triplicate) � n <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 J aquin Local Health District. <br /> Job Address <br /> Subdivision Name <br /> Owner's Name Address �!�- <br /> Contractor's Name J Phone <br /> License No. or, <br /> Phone <br /> TYPE OF WELL/PUMP 14ORK: NEW WELL WELL REPLACEMENT <br /> DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK C— X <br /> FOUNDATION SEWER LINE$ <br /> DISPOSAL FLD./�O ® PROP. LINE J <br /> AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION n J <br /> SPECIFICATIONS <br /> I J Industrial U Open Bottom Manteca .y <br /> ❑ Dia. of Well Excavation <br /> Domestic/Private Gravel PackTrac — <br /> ❑ y Dia. of Well Casing '� <br /> [] Public 4E, <br /> Li Other Delta <br /> LjIrrigation Approx, Eastern Type of Casing <br /> ❑ Cathodic Protection Depth Specifications <br /> ❑ Geophysical Depth of Grout Seal <br /> Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Dane ❑ Type of Pump �u j H.P. 3 State Work Done <br /> Well Destruction ❑ 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 .k <br /> Installation will serve: Residence Commercial Other available within 200 feet.) d <br /> Number of living units; Number of bedrooms Lot size J <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ C <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS [j Depth Size Number <br /> SUMPS ❑ 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 workmant compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the fallowing: "I certify that in the performance of the work for which <br /> this permit is issued, I shall employ p sons subject to workman's compensation laws of California." <br /> The applicant mus fo e r pections. Complete draw' on r e side. <br /> Signed X Title: Date: <br /> PARTMENT S N L Y 8 <br /> Application epted by Area �tk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspectio Date Manteca 823-7104 <br /> Final Inspection by Date Z� /li Tracy 835-6385 <br /> Applicant - Return all copi s to: Environmental Health Permit/Services 160 E. H zeiton (� P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />