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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �p q <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 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. 1862 for well/pump <br /> and the Rules and Regulations of.the San Joaquin Local Health District. CA <br /> Job Address '?//5— SOv L .4 Subdivision Name <br /> Owner's Name v ( Address Phone <br /> Contractor's Name or 's 1q- _ License No. ail Phone v <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ pO <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �f1 <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 /> Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well Casing <br /> ❑ Public ❑Other ❑Delta Type of Casing <br /> U Irrigation Approx. Eastern Specifications <br /> Cathodic Protection <br /> ❑ Depth Depth of Grout Seal <br /> L7 Geophysical Type of Grout <br /> 1­10ther Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. 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 U REPAIR/ADDITION [A (No septic tank or seepage pit permitted if public sewer is - 9 <br /> available within 200 feet.) i <br /> Installation will serve: Residence _#0 Commercial _ Other -� f <br /> Number of living units: �(_ Number of bedrooms 3 Lot size C-�• ; <br /> Character of soil to.a depth of 3 feet: --sr,4neg Water table depth <br /> SEPTIC TANK U Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method. of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE VS No. & Length of lines ^ o Total Igngth/size O O a <br /> FILTER BED ❑ Distance to nearest: Well eCJZ Foundation Property Line v <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 workmant 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,cal for all d i ct' s . Complete drawing on `verse std . <br /> Signed X Title: Date: <br /> RTMENT USE ONLY <br /> Application Accepted by _Area ❑ Stk 466-6781 <br /> Additional Comments: [] Lodi 369-362.1 <br /> Pit or Grout Inspection by Date Manteca 823-7104' <br /> Final Inspection by Date / � ❑ Tracy 835-6385 <br /> Applicant Return all copies 61 L9vironmental Health Permit/Services 1601 E. azelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE�7 ;7PERMIIT NNO. rte/ <br /> INFO i< d d -c06 <br /> EH 13-24 REV. 10/B2 10182 500 <br /> -1416— <br />