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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �� <br /> Telephone (209) 466-6781 <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein oQ <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump (y4 . <br /> and the Rules arcl Re&Ul o of the San Joaquin Lwal Health District. t_d_L1� rs�� <br /> Job Address b ion Name tV Q <br /> Owner's Name Address Phone r- <br /> Contractor's Name nse No. lnz �3 & 79Phone <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 FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing <br /> ❑ Public ❑ Other ❑ Delta Type of Casing � <br /> F-1 Irrigation Approx. ❑ Eastern Specifications <br /> ❑ Cathodic Protection Depth Depth of Grout Seal <br /> ❑Geophysical J <br /> •� —Type of Grout- <br /> ❑Other <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H•P, State Work Done C1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') r A <br /> Depth Filler Material (Below 50') <br /> Ctl <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.) G <br /> Installation will serve: Residence Commercial _ Other (�l <br /> Number of living units: Number of bedrooms Lot size / 4 ! I % <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC'JANK ❑ Type/Mfg �/9� Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg P111apacity Method of Disposal <br /> SEWAGE.SYSTEM Distance to.nearest: Well d tion Pro erty Line .- <br /> DESTRUCTION <br /> LEACHING LINE ❑ No. & Length of linesTotal length/si1perty <br /> FILTER BED ❑ Distance to nea,est�: Well Foundation Pry Line <br /> SEEPAGE PITS [ j Depth Number <br /> SUMPS Distance to nearest: Well Foundation Pr pert Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done inccordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health Distric . <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the_r <br /> of the work for which this <br /> permit is issued, I shall not employ any person in such manner as to become subject�t"o w`c kman 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 applicant knustxAlll rf ui ed inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: (-( <br /> % OR P R ENT USE ONLY ���� <br /> Application Accepted by Area ❑ Stk 466,6781 <br /> Additional Comments: ! Lodi 364-3621 <br /> Pit or Grout Inspection by Date ❑ Manteca 82377104 <br /> 11 Final Inspection by Date ❑ Tracy . 835-6385 <br /> , pplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> �- <br /> FEEO BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO.INF <br /> V -3 3r L <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />