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- w APPLICATION FOR PERMIT <br /> - i <br /> SAN ,iOAQUIN LOCAL HEALTH DISTRICT ff <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. r 1� <br /> Telephone (209) 466-6781 <br /> - <br /> PERMIT EXPIRES 1 YEAR FROM DATE I55UED 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 th'e Rules and Regulations of the-San Joaquin Local Health District. <br /> ,lab 4Address Subdi v' ion,Name <br /> t <br /> Owner's Name ` Address Phone <br /> Contractor's N me License No, 2 Phone ,7_Z57-7 <br /> 3 <br /> .TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ QA <br /> ?UMP 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 /> VI) <br /> - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 17 Industrial0 <br /> ❑ Open <br /> Bottom ❑ Manteca Dia. of Well Excavation --�; <br /> ❑ Domestic/Private 1 ❑Gravel Pack ❑ Tracy Dia, of Well Casing <br /> ❑ Public ❑Other- --E] Delta 7YPe ai Casing <br /> Irrigation a <br /> Approx. ❑ Eastern <br /> ❑ <br /> Depth Specifications,, <br /> Cathodic Protection ions,, <br /> ❑Geophysical q-- �""'""" Depth-of- Grout,Seal_ <br /> I Other i Type of Grout <br /> Surface Seal,Installed. by <br /> Repair Work Done.❑ Type of Pump H.P. State Work Done elm � J1 1 <br /> Well Destruction ❑ Weli Diameter Sealing Material (top 501) 1� a <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION U (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 /> 'F <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 /> ' Distance to nearest: Well Foundatibn Property Line <br /> LEACHING LINE ❑. No. & Length of lines Total length/size t <br /> FILTER BED, ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ "Depth Size Humber , <br /> SUMPS -` ❑ `jDistance 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 i <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 applicant must call r all required-,inspections. Complete drawing on reverse side. E <br /> Signed X �{�t�D� Title: Date: <br /> F DEp MENT.USE ONLY ^^ <br /> � <br /> Application Accepted by Area 07 ❑ Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date ❑ Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Envi onni4al 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 /> yY -13 <br /> EH 13-24 REV. 10/82 <br /> 14-26 30/82 500 <br />