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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />+" 1601 E. HAZELTON AVE., STOCKTON; CA PERMIT NO, <br /> Telephone (209) 466-6781 - ` <br /> DATE ISSUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />+ (Complete it 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 /> Job Address I <br /> Subdivision Name <br /> Owner's Name <br /> Address p Phone <br /> Contractor's Name �/Yr�� License No. ' 7 Phone <br /> TYPE OF WELL/PUMP WORK: NEO WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION '--SYST'EM`REPATR <br /> El <br /> DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE " TY1E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E Industrial .0 Open Bottom Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Uia.-of Well. Casing <br /> Public CI Other Delta } <br /> Type-of Casing <br /> Loi Irrigation ` Approx. + Eastern ' { <br /> Cathodic Protection Depth < Specifications <br /> Geophysical <br /> Depth of Grout Seal <br /> - `- ;" . <br /> OtherType of Grout <br /> 1 - Surface Seal Installed by <br /> Repair Work Done E] Type of Pump: H.p. i State Work Done <br /> Well Destruction'L_I Well Diameterl Sealing Material (top 501) <br /> Depth 'l Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO � REPAIR/ADDITION � (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: <br /> Number of bedrooms ':? Lot size <br /> Character of soil to a depth ofl3 feet: - Water table depth z <br /> 1 1i <br /> SEPTIC TANK E?-' Type/Mfg �' ' Capacity No. Compartments ' <br /> PKG. TREATMENT PLT. Type/MfgCapacity Method of Disposal <br /> SEWAGE SYSTEM cy Distance,to nearest: Well Foundation `� Property Line a <br /> DESTRUCTION � '�—' �� <br /> LEACHING LINE a No. & Length of lines -� 6 Total length/size ei <br /> FILTER BED Distance to nearest: Well Foundation 11,9 Juir—Property Line <br /> SEEPAGE PITS Depth �� }-t` Size Number <br /> SUMPS J Distance lo nearest: Well -"F oundation I Property Line <br /> DISPOSAL PONDS ❑ -4—� <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 workmant compensation laws of California." I <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." 1 <br /> The applic t must call for required inspections. Complete drawing on reverse side, <br /> Signed X -� Title: Date: "� 7 <br /> FO DEPARTMENT USE 0 Y <br /> Application Accepted by v Area "� 1 -_ Stk 466-6781 <br /> Ad itional Comments: Lodi 369-3621 <br /> or Grout Inspection bylDate Manteca 823-7104 <br /> Final Inspection byDate ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: . Environmental H� lth Permit/Services 16 1�E��eltorf Avdl! P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> jW <br /> EH 13-24 REV. 10/82 + '" 10/82 500 <br /> 14-26 t <br />