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1 , <br /> APPLICATION FOR PERMIT <br /> SAN ,OAQuiNl LOCAL HEALTH ',:STRICT41 <br /> 1501 E. HAZELTON AVE., STOCKTON, Ck <br /> z lIT No. <br /> Telephone (209) 456-6781 DATE ISSUED <br /> PERMIT EXPIRES 1-YEAR FROM DATE. ISS �P <br /> �. • (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a p <br /> ermit 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 /> Subdivision Name <br /> Job Address D Phone <br /> Owner's Name t 1 .Address d <br /> Phone <br /> Contractor's Name License No., 6,2-37-3 <br /> TYPE OF WELL/PUMP WORK: NEW WELL L] WELL REPLACEMENT DESTRUCTION 71 <br /> PUMP INSTALLATION SYSTEM REPAIR 17 OTHER LI PROP. LINE <br /> DISTANCE To NEAREST: SEWER LINES DISPOSAL FLD.SEPTIC TANK a OTHER WELL PITS/SUMPS <br /> FOUNDATION 1 AGRICULTURE WELL <br /> CONSTRUCTION SPECIFICATIONS �. -•-� - - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA _ ��._ -.- <br /> `"" Dia. of Well Excavation <br /> !!❑..Industria.l —= —���P en�gvtiworn�°-❑ Manteca <br /> Trac Dia. of Well Casing <br /> estic/Private ❑ Gravel Pack ❑ Y <br /> ' <br /> } ❑ Public [j otherDelta <br /> F ❑ Type of Casing <br /> Ek Ljlrrigation I1 Approx. 0,Eastern Specifications <br /> i Depth Depth of Grout Seal <br /> F Cathodic Protection <br /> Geophysical ; Type of Grout <br /> U Other Surface Seal Installed by e _ <br /> e 3 - H.P. <br /> Well Destruction ❑ Well Diameter <br /> State Work Done <br /> L ! <br /> Repair Work Done YP of Pump � <br /> I Sealing Material (top 50') J <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 /> available within 200 feet.) <br /> 1 <br /> Installation will serve: Residence Commercial Other <br /> -1 Number of bedrooms Lot size <br /> Number of living units: Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No. Compartments <br /> Capacity Method of Disposal <br /> f PKG. TREATMENT PLT. U Type/Mfg Property Line <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation P y <br /> DESTRUCTION I r <br /> y` LEACHING LINE U Na. & Length of lines <br /> Total length/size <br /> FILTER BED. - ❑ Distance to nearest: Well <br /> Foundation Property Line <br /> . . SEEPAGE PITS-.-.P- Dept <br /> Size Number. . <br /> SUMPS LI Distance to nearest: Well <br /> Foundation Property Line <br /> 1 DISPOSAL PONDS ❑ <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 /> k Home owner or licensed agent'sisignature certifies thesucfollow nas to becomeg: 111 ysubjectthat ntohworkman compensaterformance of honwlawsfof California." <br /> son permit is issued, I shall not:employ any p <br /> Contractor's hiring or sub-contracting signature certifies the follow <br /> this permit is issued, I shal,ljemploy p mpensatianrlaws oftify aCaliforniaerformance of the work for which <br /> The applicant must call for all required inspections. Complete drawing on reverse side. Date. <br /> Title: <br /> Signed X 4 /7 <br /> � „. A Ff�1R DEPARTMENT USE ONLY Area G./� 5tk 466-6781 <br /> Application Accepted by N/� e — ❑ Lodi 369-3621 <br /> Additional Comments: ❑ Manteca 823-7104 <br /> f Pit or Grout Inspection by Date <br /> Date - ❑ Tracy 835-6385, <br /> 35Stk., <br /> Final Inspection by <br /> F <br /> Applicant - Return all copies+to: . Environmental Health Permit/Services 1641 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . <br /> DATE PERMIT N0. <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY / <br /> INFO 'A �L/ <br /> 10/82 509 <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />