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APPLICATION FOR PERMIT <br /> SAN JOAQL'iN LOCAL HEALTH DISTRICT �� �`��( <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ly `� <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES I 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. <br /> Job Address � A. j[f Subdivision Name <br /> Owner's Name /,(J Address }/¢ jPhone <br /> Contractor's Name �1fjCJS License No. <br /> 1-1?...__._.,�._. Phone <br /> o/1 <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ (� <br /> PUMP INSTALLATION L] SYSTEM REPAIR OTHER ❑ 1 <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 /> I J Industrial U Open Bottom F-I Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing <br /> ❑ Public ❑Other ❑ Delta Type of Casing <br /> Lj Irrigation Approx. ❑ Eastern <br /> ❑ Cathodic Protection <br /> Depth Specifications <br /> I�Geophysical Depth of Grout Seal <br /> LJ Other Type of Grout <br /> Surface seal Installed by <br /> Repair Work Done [J- Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (tap 50') <br /> Depth Filler Material (Below 50') <br /> C� <br /> TYPE OF SEPTIC .WORK:, NEW INSTALLATION REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SE7TIC TANK ' Type/Mfg apacity l _ No. Compartments 7— <br /> PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well j!J i Foundation {d Property Line - _ <br /> DESTRUCTION ❑ <br /> LEACHING LINE U 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 ❑ 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, 1 shall not, employ any person in such manner as to become subject to workman compensation laws of California." <br /> Contractor's h' ing or sub-contracting signature certifies the folly "I certify that in the performance of the work for which <br /> this permit i sued, I shall employ per ons subject to workman' c_ ensation laws of California." <br /> The applic t call fo 11 requir inspectVons. Complete drawing on Epyerse side. <br /> Signed Title: Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by R R Area , Stk 466-6761 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by i Date —1 w_. +?_,. Tracy 835-6385 <br /> 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 /> EH 13-24 REV. 10/82 ,. . . 10/B2 500 <br /> 14-26 <br /> F <br />