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�v <br /> APPLICATION FOR PERMIT <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.' HAZELTON AVE., STOCKTON, CA PERMIT N0. d f <br /> Telephone (209) 466-6781 <br /> DATE ISSUED � M <br /> PERMIT EXPIRES l 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. 1862 for well/pump <br /> and the Rules and Regulations of the San Joaquin Local Health District. <br /> ision Name <br /> Job AddressPhone <br /> No, <br /> — <br /> Owner's Name Address <br /> Contractor's Name <br /> la f , License Phone pQ <br /> DESTRUCTION w <br /> TYPE OF WELL/PUMP WORK: NEW,1WELL ❑ WELL REPLACEMENT ❑ ❑ <br /> OTHER <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR U <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIG TANK � PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL'_.- <br /> PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS <br /> Industrial F-1openBottom ❑Manteca <br /> Dia. of Well Excavation <br /> Domestic/Private. ❑ Gravel Pack ❑Tracy Dia. of Well Casing <br /> ❑ Public ❑ Other ❑Delta Type of Casing <br /> Irrigation Approx. Eastern . <br /> ❑ Specifications <br /> ❑ Cathodic Protection Depth <br /> pep�h of Grout Seal <br /> ❑Geophysical _ Type of Grout <br /> ❑0ther. Surface Seal Installed by <br /> Repair Work Done � Type of Pump <br /> H P State Work Done <br /> i 5ealin Material (top 50') ! <br /> Well Destruction L} Well Diameter: g UJ <br /> Depth t -,Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION F-1 REPAIR/ADDITION ❑ (No septic tank or seepage p}avaelableewithinu200cfeetsew�) is <br /> Installation will serve: Residence Commercial,_ Other <br /> Number of living units: Number of bedrooms Lot size <br /> Water table depth <br /> Character of soil to a depth of`3 feet: No. Compartments <br /> SEPTIC TANK I Type/Mfg Capacity <br /> + Capacity Method of Disposal .r� <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Property Line <br /> SEWAGE SYSTEM Distanc� to nearest: Well Foundation A Y <br /> DESTRUCTION <br /> No. & Length of lines Total length/size <br /> LEACHING LINE U g Property Line <br /> FILTER BED ❑ Distance to nearest' Well Foundation P y <br /> Depth Size Number. <br /> SEEPAGE PITS ❑ I- <br /> Foundation Property Line <br /> SUMPS �� Distance to nearest: Well _ <br /> DISPOSAL PONDS ❑I x <br /> application and that the work will be done in accordance with San Joaquin county <br /> I hereby certify that 1 have prepared this app' <br /> ordinances, state laws, and rules and regulations of the San Joaquin L cal Health Districperformance of the work for which this <br /> Home owner, or licensed agent's signature certifies the following' <br /> permit is issued,, I shall, not employ any person, in such manner as to become subject to workmant compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:' "; 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 applicant must all all required inspections. Complete dr ing nn reverse side. Date: <br /> Signed X ' � . <br /> Title: <br /> F ARTMENT USE ONLY j ❑ St{� 466-6781 <br /> Application Accepted by i Area _-fir -- <br /> ❑ Lodi 369-3621 N <br /> Additional Comments: Manteca 823-7104 <br /> Pit -or•Grout Inspection by Date l <br /> Final Inspection by <br /> Date . L7 Tracy 835-63$5 If <br /> 4 <br /> Applicant - Return all copies to: Environmental Health Permit/'Services 1601 F. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 <br /> I <br /> FEE BASE AMOUNT' DUE AMOUNT REMITTED RECEIVED BY <br /> DATE <br /> PERMIT NO. <br /> INFO J � �_ ,.-,"'ylT��`� <br /> 3 f 10/82 <br /> EH 13-24 REV. 10/82 •�" NuYI ()f f <br /> 14-26 <br />