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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> a <br /> Telephone (209) 466-6781 x DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application i <br /> This application is made in compliance s hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> described. 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 L cal Health District. <br /> Subdivision Name "f } <br /> Job Address � Phone L <br /> Owner's Name Address <br /> contractor's N e <br /> ' License Na. Phone <br /> �- <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑L.� <br /> INSTALLATION SYSTEM REPAIR <br /> PUMP ❑ <br /> OTHER ❑ , <br /> DISTANCE TO NEAREST: SEPTIC TANK ! SEWER.LINES f r DISPOSAL FLO. rPRDP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIDNS <br /> Industrial pen Bottom Manteca Dia, of Well Excavation ' <br /> omestic/Private Gravel Pack Tracy <br /> Dia. of Well Casing <br /> ❑ Public ❑Other Delta ` <br /> ❑ Type of�Casing + <br /> irrigation Approx. Eastern ¢ f <br /> g ❑ Specifications # <br /> ❑Cathodic Protection Depth ' <br /> �� Depth of Grout Seal <br /> ❑Geophysical Type of Grout' <br /> F ❑Other { Surface Seal Installed by <br /> Repair Work Done Type of Pump H ? rY <br /> State Work ne /6_1 " A <br /> Well Destruction pT `Well diameter rr Sealing Material{top 50') <br /> Depth,' �� Filler Material (Below 501 <br /> 1 <br /> TYPE OF SEPTIC WORK: NEW,INSTALLATION FI REPAIR/ADDITION U (No septic tank or seepage pit <br /> availableewithin d if u200cfeete) .�s1'I t <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: * Number of bedrooms Lot size , <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> ` SEPTIC TANK Type/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PLT. Type/Mfg <br /> Capacity Method of Disposal <br /> SEWAGE SYSTEM r. _ Distance_to-Distance - Foundation. <br /> DESTRUCTION _Property Line <br /> .,, <br /> { LEACHING LINE—"^"'" U -­No. &'Length-ofalines <br /> _ r -.'Total=1e'69th/size�.�•. <br /> FILTER BEDS Distance to nearest: Well Foundation Property Line <br /> I ' Number <br /> SEEPAGE PITS r ❑ Depth Size <br /> SUMPS-1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> Irhereby 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 /> c � Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> ,3 F permit is issued, I shall not employ any person in such manner as to become subject to workman compensation laws of California."i <br /> w 7 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 loy persons subject to workman's compensation laws of California." <br /> »> 'The applic nt t call For a equir inspections. Complete dr ng on reverse side. Date: <br /> : Title: <br /> Signed X ^� <br /> FOR DEP RTMENT USE ONLY Stk 466-6781 <br /> A lication Accepted by Area <br /> Lodi 369-3621 <br /> Additional Comments: Manteca 823-7104 <br /> 1 Pit or Grout Inspection Dat ._LL <br /> Date �0 Tracy 835-6385 <br /> Final Inspection by <br /> Applicant - Return all copi nvironmental Health Permit/Services 160 E. azelton Ave., P.O. Box 2009, 5t k., CA 95201 <br /> NT REMITTED RECEIVED BY DATE PERMIT NO. <br /> i FEE BASE AMOUNT DUE AMOUNT b_,0_ <br /> Jii <br /> ` INFO — O <br /> oS. o� <br /> 10/82 500 d <br /> EH 13-24 REV. 10/82 C� q/x <br /> 14-26 Y <br />