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N� <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT II`'7 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. �— �r <br /> Telephone (209) 466-6781 <br /> GATE ISSUED 1a1-7 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> R. 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 Regulations of the San Joaquin ocal Hea th District. <br /> p Job Address 6division Name <br /> Owner's NameAd re Phone <br /> Contractor's Name-O" se 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 FLO. PROP, LINE } <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 'J <br /> 17 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Dia, of Well Casing <br /> ❑ Public ❑Other ❑ Delta <br /> Type of Casing <br /> Li irrigation Approx. ❑Eastern <br /> ❑ Cathodic Protection Depth Specifications <br /> Depth of Grout Seal <br /> ❑Geophysical <br /> Type of Grout <br /> E❑Other <br /> Surface Seal Installed by <br /> Repair, Work Done F) Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> — r.. 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 /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line <br /> DESTRUCTION ❑ <br /> LEACHING LINE ❑ No, & Length of lines Total length/size { <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size 1J 91 Number r <br /> SUMPS Distance to nearest: Well �undation Property Line <br /> DISPOSAL PONDS ❑ /�'I�T �, <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 applican call or all r fired inspections, omplete drawing reve se side p <br /> Signed X Title: ✓ C Date: <br /> F DE PA ENT USE ONLY <br /> Application Accepted by Area Stk 66-67 <br /> Additional Comments: �A / ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date <br /> Manteca 823-7104 <br /> Final Inspection by — Date Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BR SE AMOUNT DUE AMOUNT REMITTED RECEIVED BY `` DATE.q Q PERMIT NO. <br /> INFO <br /> EH 13--24 REV. 10/82 10/82 500 <br /> 14-26 <br />