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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �—7o7 <br /> Telephone (209) 466-6781 <br /> �Z-b gZ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 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 Reguiations of the San Joaquin Local Health District. <br /> Job Address �' '00110%40 Subdivision Name <br /> Owner's Name Address Phone (t <br /> Contractor's Name .ticense No. — 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 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 17 Industrial ❑Open Bottom ❑Manteca Dia, of Well Excavation <br /> Domestic/Private Gravel Pack Tracy Dia, of Well Casing <br /> Public F-1 Other Delta <br /> Type of Casing <br /> LjIrrigation Approx. ❑ Eastern <br /> Depth Specifications <br /> Cathodic Protection p Depth of Grout Seal <br /> Geophysical <br /> Type of Grout <br /> Other <br /> Surface Seal Installed by <br /> Repair Work Done [I Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') � o � <br /> Depth Filler Material (Below 50') . ,•„ _ _ ,� w <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 sail 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 /> Septic Tank > Distance to nearest: Well Foundation Property Line <br /> Destruction <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation Property 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 . iss shall employ persons subject to workman's compensation laws of California." <br /> The applicant u a f a r uired inspections. Complete drawing on reverse side. <br /> Signed X. Title: 0"4rZC21L1 ` Date: �— <br /> D P RTMEV PSE ONLY <br /> Application Accepted b A"4'k Area Q 3 Stk 466-6781 <br /> Additional Comments: 67 Lodi 369-362.1 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date / "Z. # Tracy 835-6385 <br /> Applicant - Return all copies o: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 11 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> Z . m o Cmc 1' $ _-7a:7 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 N <br />