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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON. CA <br /> Telephone (209) 466-6781 PERMIT NO. :3 �,Q <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED. ' 3 <br /> F o <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 <br /> described. This application is made in compliance with San Joaquin County-Ordinance No. 549 for sewage or No. 1862 f <br /> and the Rules and Regulations of,the San Joaquin Local Health District, herein <br /> Job Address w or well/pump <br /> r Subdivision Name. <br /> Owner's Name , A <br /> Contractor's Name Address <br /> ft 9405­ aa+v License No. lr'vL�,� Phone <br /> TYPE OF WELL/PUMA WORK: Phone D <br /> NEW WELL ❑ WELL REPLACEMENT ❑ <br /> ` PUMP INSTALLATION DESTRUCTION <br /> � DISTANCE TO NEAREST: SEPTIC TANK � ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES <br /> FOUNDATION DISPOSAL FLA" d <br /> AGRICULTURE WELL PROP. LINE <br /> INTENDED USE OTHER WELL ^ PITS/SUMPS " <br /> r ❑ Industrial TYPE.OF WELL PROBLEM AREA <br /> El CONSTRUCTION SPECIFICATIONS d <br /> f ❑ DOmestic;Private Open Bottom ❑Manteca <br /> ❑ Dia. of Well Excavation <br /> Gravel Pack <br /> E ❑ Public [] Tracy� <br /> Other Dia" of Well Casing j ❑ ' <br /> Irrigation Del to <br /> ❑ <br /> Approx. <br /> ❑ Eastern Type of Casing <br /> Cathodic Protection —,-,Depth_ <br /> Specifications <br /> ❑Geophysical <br /> E i Depth of Grout <br /> F1Other Type of Grout Seal <br />' Repair Work DoneSurface Seai.Installed by tfj <br /> ❑ TYPe of Pump H P <br /> Well Destruction ❑ Well Diameter, State Work Done <br /> � Sealing Material (top 50') � <br /> Depth 1 1 <br /> Filler Material (Below 501) -- f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION <br /> [J REPAIR/AI TION (No septic tank or see <br /> Installation will serve: Residence Page Pit permitted if public sewer is <br /> Number of living Commercial Other available within 200 feet.) <br /> t i units: �� Number Of bedrooms <br /> Character of $oil to a depth of 3'feet: Lot size <br /> SEPTIC TANK <br /> Type/Mfg Water table depth ��q <br /> PKG. TREATMENT PLT, ❑ Type/Mfg Capacity - _ No . Compartments <br /> Distance to nearest: Well ,� Capacity Method of Disposal <br /> �y Foundation �� Property Line <br /> LEACHING LINE E] No" & Length of lines <br /> FILTER SEDE] Distance to nearest: Well Total length/size <br /> SEEPAGE PITS Foundation �� property Line ` f <br /> SUMPS <br /> ❑ Depths Size <br /> L_1 Distance to: nearest: Well Humber <br /> DISPOSAL PONDS Foundation <br /> ❑ y ounation �`� Property Line ` <br /> i <br /> T hereby certify that I have Preparedthisapplication and that the work will be done in accordance with San Joaquin <br /> ' <br /> ordinances, state laws, and rules andiregulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the folaowin q county <br /> permit o issued, I shall not employ any person in such manner as to becomeysubject that ntohworkman compensathonwlawsfof-rCaliforn?s <br /> Contractor's hiring or sub-contracting signature certifies the following: e certify that in the performance of the work <br /> this permit is issued <br /> , I shall employ persons subject to workman's compensation laws of Californiae la." <br /> The applicant must call for all required insp tions" Complete drawing for which <br /> Signed Xy g c reverse de" <br /> Title: <br /> Application Accepted by F AR MENT USE'ONLY Date: — <br /> Additional Comments: Area <br /> Stk 466-6781 a <br /> Pit or Grout Inspection by <br /> ❑ Lodi 369-3621 <br /> Final Inspection by Date Q Manteca 823-7104 ° <br /> Applicant - Return all copies to: Environmental Health Permit/ServicDese1G01 E/Hazelton <br /> ❑ Tracy 835-6385 <br /> BASE <br /> FEE DUE AMOUNT REMITTED Ave., P.O. Box 2009, Stk", .CA 95201 <br /> AMOUNT <br /> INFO RECEIVED BY <br /> DATE PERMIT NO. <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />- <br /> 10182 500 + <br />