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APPLICATION FOR PERMIT <br />SAN JOAQUiN LOCAL HEALTH DISTRICT <br />1601 E. HAZFLTON AVE., STOCKTON, CA s PERMIT NO. <br />Telephone (209) 466-6781 1 <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 Rul4Ne <br />Regulations f t e Sp . jo qui .Local Health District. <br />Job Address 4 Subdivision Name <br />Owner's NamPhone <br />Contractor'Li ense No. Phone <br />TYPE OF WELL/PUMP WORK: NEW WELL Y4i-WELL REPLACEMENT DESTRUCTION <br />PUMP INSTALLATION 0 A5Y5TEM REPAIR L7 OTHER U <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER -LINES DISPOSAL FLD, <br />FOUNDATION AGRICULTURE WELL OTHER WELL <br />INTENdED USE <br />Industrial <br />U Domestic./Private' <br />LD Public <br />L Irrigation <br />❑ Cathodic Protection <br />0 Geophysical <br />U Other, " I <br />Type of Pump <br />Well Diameter <br />Depth 1 <br />TYPE OF WELL <br />PROBLEM AREA <br />CONSTRUCTION SPECIFICATIONS' <br />U Open Bottom <br />r <br />0 Manteca <br />Dia. of <br />Well Excavation _ <br />—,F-1 Gravel: Pack -5-. - <br />Q Tracy ".. <br />_. Dia. of <br />Ye1��Casing _..� <br />Other <br />Delta <br />Type of <br />Casing <br />Approx. <br />Depth <br />® Eastern • Specifications <br />I s, <br />Repair Work: Done ❑ <br />Well Destruction <br />Depth of Grout Seal <br />type of Grout <br />Surface Seal Installed by <br />H, -P", State lorkADone <br />Sealing Material (top tD' ) <br />Filler Material I(Below.,50',.)3: „- <br />_ PROP. LINE W <br />PITS/SUMPS <br />M <br />.w Y" k <br />TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank orseepagepit-permitted if public sewer is <br />+ + available within 200 feet.) <br />Installation will serve: Residence vCommercial Other <br />Number of living units: ._---�= Number of bedroomsLot sizeQ <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK [4�__ Type/Mfg Capacity Z_ �(f 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 No. & Length of lines Total length/size <br />FILTER BED EJ Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS Depth Size Number F <br />SUMPS Jam' Distance to nearest: Well- Foundation.—�"= -Proper-ty;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 workmanb 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 applican must all for al uired irspect'ons. Complete drawing'on reverse side', t <br />Signed X + Title: Date: <br />---�� FOR DEPARTMENT USE ONLY Stk 466-6781 <br />Application Accepted by �i Area <br />Additional Comments: u 1 — � i � Lodi 369-3621 <br />Date Manteca 823-7104 <br />Pit or Grout Inspection b U <br />Final Inspection by Date L7 Tracy 835-6385 <br />Applicant - Return all copie o: Environ -ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />TEE EASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE q PERMIT GNC. <br />10/B2 500 <br />EH 13-24 REV. 10/82 <br />14-26 <br />M <br />