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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE 1ISSUED <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 o,nthe San Lo s of Joal Health District. <br /> Job Address � N Subdivision Name <br /> Owner's Name F+ Address Phone <br /> Contractor's Na License No. Phon <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �� <br /> PUMP INSTALLATION SYSTEM REPAIR U OTHER ❑ Q <br /> DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES DISPOSAL FLO. PROP. LINE { <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> T-1 Industrial <br /> PBpen Bottom ❑ Manteca Dia. of Well Excavation <br /> E^Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing <br /> t <br /> ❑ Public ❑ Other ❑ Delta Type of Casing r <br /> Irrigation Approx. ❑ Eastern — <br /> Depth Specifications <br /> ❑ Cathodic Protection P <br /> ❑ Geophysical Depth of Grout Seal O <br /> Type of Grout L <br /> ❑Other Surface Seal Installed by 'jg^A <br /> Repair Work Done ❑ Type of Pump 5 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 ❑ REPAIR/,ADDITION ❑ (No septic 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 Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑! Type/Mfg 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 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS CI <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 workman§ compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance ofithe work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. f' <br /> Signed X Qzr�Mz�, J Title: Date: �~ V7 <br /> '"'�/ FOR DEP T�E <br /> Application Accepted by rnQ a <br /> Area jS ❑ StkAdditional Comments: � Lodi 369-3621 <br /> Pit or Grout Inspection by" Date ❑ Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 R <br /> Applicant - Return all copies 014 Wo­—t-7 Health Permit/Services 1601/E. zelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO _ <br /> EH 13-24 REV. 10/82 �3! 10/82 500 <br /> 14-26 ✓{ <br /> I <br />