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APPLICATION FOR PERMIT i <br /> I <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 /> (Com.plete in Triplicate) <br /> Application is hereby made po the San Joaquin Local Health District for a permit to construct and/or install the work herein <br /> described. Thi p t� y� e in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wel3/pump <br /> J nd�e ul es a d R iYT n l'►F►tie San Joaquin Local Heal thY6i seri try t <br /> b AdU"ress y� Subdivision Name <br /> Owner's Name Address Phone <br /> Contractor's Name �1 License No. {�-[ Phone ,2• <br /> TYPE OF WELL/PUMP WORK: NEW WELL IJV WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK d D` SEWER LINES ��T DISPOSAL FLD. [ddb`-PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS N <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IJ dustrial Open Bottom 71 Manteca Dia. of Well Excavation I t It �I <br /> I <br /> ' Domestic/Private Gravel Pack Tracy Dia. of Well Cas'ng <br /> Public [j Other L] Delta lI ' <br /> Irrigation Type of Casing <br /> u g Approx. Eastern Specifications Q <br /> Cathodic Protection p <br /> Depth of Grout Seal <br /> L7 Geophysical <br /> Type of Grout O <br /> U Other <br /> Surface Seal Installed by 4 /,4w- <br /> 5 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction LJ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EI 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 j <br /> Number of living units: Number of bedrooms Lot size <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 /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE U No. & Length of lines Total length/si7e' h <br /> FILTER BED Distance to nearest: Well Foundation Property Line l <br /> SEEPAGE PITS ❑ Depth Size Number <br /> I' <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS r <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 fallowing: "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 workmanis 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 emplo persons subject to workman's compensation laws of California." <br /> The applican us all f all re ired inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FOR A T NT U ONLY <br /> Application Accepted by Area a C1 ❑ Stk 466-6781 <br /> Additional Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date j Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: vironmental 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. r <br /> INFO 041 <br /> 2� <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />