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i <br /> js APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA -7a <br /> Telephone (209) 466-6781 PERMIT NO. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 N <br /> l <br /> and the Rules and Regulations of the San Joaquin LocaHealth District. o. 1862 for well/pump <br /> Job Address <br /> j <br /> Owner's Name Address Subdivision Name <br /> ,� ` <br /> Contractor's Name - Phone <br /> License No. Phone �K, <br /> TYPE OF WELL/PUMP WORK: NEW WELL , <br /> WELL REPLACEMENT Q DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL F OTHER WELL PITS/SUMPS <br /> f INTENDED USE TYPE OF WELL PROBLEM AREAO <br /> CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial U Open BottomManteca <br /> 17 Domestic/Private � Dia. of Well Excavation - <br /> Gravel Pack Tracy Dia. of Well Casing <br /> Public Other <br /> — LJ ❑ Delta ' <br /> Irrigation T <br /> LJ 9 Approx. Eastern Type of Casing„ <br /> Cathodic Protection Depth Specifications ' <br /> Geophysical Depth of Grout rSeal t------------_ <br /> Other Type of Grout <br /> Repair Work Done Type of Pum Surface Seal Installed by , <br /> YP P H.P. State Work Done ' <br /> Well Destruction Well Diameter - Sealing Material (`top 50') <br /> Depthfilr <br /> ler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION <br /> [-I (Noseptic tank or seepage pit permitted if public sewer is � <br /> Installation- will serve: Residence ' Commercial _ Other available within 200 feet.) ` <br /> Number of living units: _ Number of bedrooms <br /> Lot size � � <br /> Character of soil to a depth of 3 feet: p � <br /> SEPTIC TANK Water table depth <br /> Type/Mfg �:tCapacity �No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg s <br /> Capacity. Method of Disposal <br /> Distance to nearest: `Well / Foundation �— <br /> /d© _ Property Line <br /> LEACHING LINE No. & Length of lines <br /> a. <br /> FILTER BED Total length/size ��f�f s + <br /> �• Distance to nearest: Well Fo ndation X, <br /> Property Line ` <br /> SEEPAGE PITS Depth ---j .�— Size J f Number _ <br /> SUMPS J Distance to nearest: Well Foundation <br /> DISPOSAL PONDS -- U f Property Line <br /> f <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 i <br /> permit is issued, I shall not employ any person in suc <br /> Contractor's hiring or sub h manner as to become subject to workman§ compensation laws of California." <br /> -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 m ,t c 1 for all�req r inspe ions. Complete drawing on reterse si { <br /> Signed X a <br /> Title: Date: <br /> NDEPARTMENT USE ONLY r <br /> Application Accepted by Area — <br /> Additional Comments: lle!l �tk 466-6781- <br /> Pit or Grout Inspection by <br /> pi? <br /> � Lodi 369-3621 <br /> Date /VfX a, .Z' /�/—$Z Manteca 823-7104 ¢ <br /> Final Inspection by Date 12-1,7-0 <br /> 835-63 <br /> Applicant Return all copies to: Environmental Health Pe mit/Services 1601 EHazelton Ave., P.O.TBoxy2009, Stk85 CA 95201 j <br /> [FEE NFO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> EH 13-24 REV. 10/82 <br /> 14-26 10/82 500 <br />