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F �+� 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 i YEAR FROM DATE ISSUED <br /> 2 <br /> ; (Complete in Triplicate) <br /> Applicationishereby made to the San Joaquin Local Health District for a permit to construct anvor install the work herein <br /> described. This t' ade ]��/mpli w th n J i � e . 549 cr sewage or No. 1862 for well/pump <br /> and the Rules % the��Rf do _ <br /> Job Address l� }�7 r' +r / 4 Subdivision Name <br /> Owner's Name 1.� it Address r� �� c� �f/rV R� Phone <br /> Contractor's Name . t,1�n.�a � r-3 License No. 2,5910 Phone <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 JV `.P,:t DISPOSAL FLD. PROP. LINE <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> J Industrial i.�<Pen Bottom ❑ Manteca Dia. of Well Excavation �+ <br /> ­C.?<mestic/Private ' 7 Gravel Pack Tracy Dia. of Well Casing I <br /> �] Public [j Other Delta <br /> i <br /> V <br /> Type of Casing <br /> Irrigation Approx. Eastern Depth Specifications R <br /> + <br /> Cathodic Protection Depth of Grout Seal <br /> Geophysical t <br /> Type of Grout 9 <br /> U Other Surface Seal Installed by CyIr,, C. io �a <br /> Repair Work Done ❑ Type of Pump H.P. a. State Work Done a <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION j� (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 /> �i <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line ) <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length af'lines' Total length/size <br /> FILTER BED F__� Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> -t <br /> `SUMPS" L� —Di`stance`to'nearest: Well Foundation- 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, 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 for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> EPARTMENT USE ONLY a3-2 r6 <br /> Application Accepted by � � Area f Z qf,4Stk 466-6781 <br /> Additional Comments: Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date -,rLj Tracy 835-6385 <br /> Applican - Retur all c pies to: Envir nmerLta ealth 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 �S�o-�� b <br /> 7/ $� <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br /> �r <br />