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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. D f <br /> Telephone (209) 466-6781 1 --` <br /> DATE ISSUED /off- (p !� <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 workherein <br /> r described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump <br /> a and the Rules and Regulations of the San Joaquin Local Health District. <br /> Job Address / �.7 N. H(� Subdivision Name <br /> Owner's Name Address {��. Phone <br /> Contractor's Nam + N License No.; <br />[ �Z Phone;3k'`'�' <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT �] DESTRUCTION ` <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER <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 /> 17 Industrial U Open Bottom ❑Manteca Dia. of Well Excavation <br /> Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Public Other ❑ Delta <br /> Type of Casing <br /> U Irrigation Approx. ❑ Eastern Specifications <br /> TI Cathodic Protection - Depth - <br /> Geophysical Depth of Grout Seal <br /> p <br /> Type of Grout <br /> (Other Surface Seal Installed by <br /> { Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> a Installation will serve: Residence kl Commercial Other <br /> Number of living units: Number of drooms Lot size a«C�LCA <br /> Character-of soil to a depth of 3 feet: _ �ifC -� Water table depth _ _ZiQ� <br /> SEPTIC TANK Ej . Type/Mfg Capacity No. Compartments <br /> f PKG. TREATMENT PLT, Type/Mfg Capacity Method,of Disposal <br /> _ Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L_I No. & Length of lines _ _ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth �.� Size 3[p Number 42 <br /> r--� SUMPS U Distance to nearest: Well (9�f Foundation ��1 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 /> t 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 of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The appl"must for all required inspections. Complete drawing n reverse side. <br /> Signed XTitle: (� � Date:FOR DEPARTMENT USE ONLY Apted by Area ��- Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection4 Date Manteca 823-7104 <br /> FE Final Inspection by 1 Date Tracy 835-6385 <br /> E Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> N <br /> EH 13-24 REV. 10/82 10/82 500 <br />