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l <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. ''5-6 <br /> Telephone (209) 466-6781 <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. 1662 for well/pump <br /> and the Rules and Regulation f the San Joaquin Local Health District. <br /> Job Address Subdivision Name <br /> Owner's Name - Address Phone <br /> Contractor's Name 4. License No. Phone <br /> ti <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION W <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OT WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> IJ Industrial Lf Open Bottom Manteca Dia. of Well Excavation <br /> L j Domestic/Private Gravel Pack Tracy Dia. of Well Casing <br /> Public F-] Other ElDelta Type of Casing <br /> j� Irrigation Approx. Eastern Specifications' <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> 7] Geophysical Type of Grout <br /> U Other Surface Seal Installed by -) <br /> Repair Work Done G Type of Pump H.P. State Work Done {� <br /> Well Destruction U Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> A <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION <br /> ;< REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence A Commercial _ Other <br /> Number of living units: A— Number of bedrooms - Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity 2,900 No. Compartments R <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM ,Distance to nearest: Well1107 <br /> Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE ❑ No. & Length of lines �� Total: len h/size r <br /> 70 <br /> FILTER BED Distance_ to nearest: Well�S + Foundation 4 # <br /> Property Line <br /> SEEPAGE PITS Depth ` Size _bLl � Number <br /> SUMPS Distance to nearest: Well Foundation •- Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that.] 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 cr'sub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued,41 shall employ persons subject to workman's compensation laws of California." <br /> The appli ant rniust call for all rXte,red inspec Complete drawing on reverse side. <br /> Signed <br /> ~ -' 6') Title: Date- <br /> Si <br /> ENT USE ONLY ❑ <br /> Application Accepted by Area l� Stk 466-6781 <br /> Additioral Comments: ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 160 E. azelton Ave., P.O. Box 2009, Stk„ CA 95201 <br /> FEE BASE AMOUNT DUE RMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> 4 <br /> INF 6 r1a 13 3-5bS <br /> EH 13-24 REV. 10/92 �' ry ^� ~� 10/82 500 <br /> 14-26 <br />