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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 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 Regulat'ons of the San Joaquin L cal Health District. <br /> Job Address �j Subdivisi ame <br /> Owner's Name r Address Phone <br /> Contractor's Name 1 License No. Phone p <br /> TYPE OF WELL/PUMP WORK: NEW WELL Q `'WELL REPLACEMENT DESTRUCTION ) <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 65 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> Industrial Open Bottom <br /> R ❑Manteca Dia. of Well Excavation <br /> Domestic/Private Gravel Pack 0 Tracy Dia. of Well Casing <br /> Public Other Delta <br /> LjIrrigation " Type of Casing <br /> Approx. Eastern F <br /> [Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> #_J Other Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done EJ Type of Pump H.P. State Work Done <br /> Well Destruction Well Diameter ( Sealing Material (top 501) <br /> Depth 1 Filler Material (Below 50') _ 4__ <br /> 'TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION r Y <br /> ' L# X (No septic`tank or .seepage pit permitted if public sewer is .� <br /> Installation will serve: Residence_ Commercial _ Other available within 200 feet.) S <br /> Number of living units: 2, Number of bedrooms �� Lot size. <br /> Character of soil to a depth of 3 feet: 4 Water table depth >6 O <br /> SEPTIC TANK Type/Mfg + Capacity -No. Compartments <br /> PKG. TREATMENT PLT. Type/Mfg i Capacity -Method of Disposal <br /> Distance tc nearest: Well Foundation Property Line <br /> t <br /> LEACHING LINE No. & Length of lines �r Total length/size <br /> p )[ 7 <br /> FILTER BED ED Distance tonearest- Well / Foundation .!3. C7 Property Line -o D' <br /> SEEPAGE PITS P5 Depth Size 3 _ Number <br /> SUMPS <br /> U Distance to nearest: Well fora' Foundation i'.0P4!:> Property Line /per <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, I shall not employ any person in such manner as to became subject to workmant 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 cal,l. f all 1.red i i Complete drawing on r rse side <br /> Signed X !J- Title: Date: ' <br /> F TMENT USE ONLY <br /> Application Accepted by Area �G�, Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by , 4fe�•-.,_ Date '/ p, 3 ❑ Manteca 823-7104 <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1661 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE + AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. ` <br /> INFO i <br /> EH 124 REV. 10/82 <br /> 144-26 10/82 500 <br />