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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED (1LJ <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 Regulations of the San Joaquin Local Health District. <br /> Jab Address / r Slbd v'!I tan-N e <br /> Owner's Name (r AddressPhone <br /> Contractor's Name f License No. Phone P <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR F-1 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . <br /> Industrial ❑Open Bottom ❑Manteca Dia. of Well Excavation —2) <br /> 17y Dia. of Well Casing <br /> Domestic/Private Fj Gravel Pack Trac -F ' <br /> Public <br /> Cl Other ❑ Delta <br /> Lj Irrigation Approx. Eastern Type of Casing <br /> [-]Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> Other Type of Grout <br /> `. Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. t 1 State Work Done <br /> Well Destruction U Well Diameter Sealing Material-(top .50') <br /> Depth Filler Material (BelowI501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION �j <br /> ] (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence _ Commercial O'th`er available within 200 feet.) <br /> Number of living units: Number of bedrooms Lot size f� <br /> Character of soil to a depth of 3 feet: Water table depth 7 <br /> SEPTIC TANK U Type/Mfg Capacity No. Compartments �v1i <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal )J <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Lf No. & Length of lines Total length/size <br /> FILTER BED i ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth <br /> P � size 3 �(umber�. <br /> SUMPS U Distance to nearest: Well ZT Foundation Property Line _ f <br /> 4 DISPOSAL PONDS `` ` p y 62a -=— <br /> �____ 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.', ,I <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X � Title: �(7=r-4e,--- _. Date:, -r Z <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Areal E] Stk 466-6781 <br /> Additional Comments: [] Lodi 369-3621 <br /> Pit or Grout Inspection by Date anteca 823-7104 <br /> Final Inspection by Date E] Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental 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 N0. <br /> INFO � . <br /> EH 13-24 REV. 10/82 <br /> 14-26 �� l -� 10/82 500 <br />