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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 in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein <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 He 1 District. <br /> Job Address S,. ubdivision Name <br /> Owner's Name ' _Address Phone _ <br /> t Contractor's Name License No. Phone ErIg-27 a 7 <br /> TYPE OF WELL/PUMP WORK: NEWJWELL �] WELL REPLACEMENT (�, DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER E W <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;,lv <br /> F] Industrial u Open#Bottom ❑Manteca Dia. of Well Excavation U" <br /> Domestic/Private ❑Gravel Pack Ej Tracy Dia. of We11.Casing <br /> 17 Public E] Other Delta <br /> LjIrrigation Approx. Eastern Type of Casing <br /> Cathodic Protection Depth Specifications <br /> Geophysical , <br /> Depth of Grout Seal <br /> Other Type of Grout <br /> Surface Seal.Installed, by <br /> Repair Work Done ❑ Type of Pump N.P. State Work Done <br /> Well Destruction U - Well Diameterl Sealing Material (top 50') <br /> Depth Y ) Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> i <br /> available within 200 feet:) <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: (Number of bedrooms Lot size a <br /> Character of•soil ..to a-depth of-3 feet: Water, table depth <br /> SEPTIC TANK c Type/Mfg,i ; Capacity No. Compartments <br /> PKG. TREATMENT PLT_ Type/Mfg Capacity Method of Disposal <br /> Septic-Tank 'Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE}9 U -No. & Length of lines Total length/size <br /> FILTER BED ., Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS F—j Depth Size Number <br /> SUMPS LJ Distance to nearest: Well Foundation Property Line ! <br /> DISPO.SAL.PONDS D <br /> I hereby certify that -I have prepared this application and that the wort 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." <br /> The. applicant t all for all required inspections. Complete draw' on re rse side. <br /> Signed X <br /> 9. < Title: Date: <br /> F }DEPARTMENT USE ONLY <br /> Application Accepted by Area �� Stk 466-6781 <br /> Additional Comments: I [, Lodi 369-3621 <br /> i <br /> Pit or Grout Inspection by Date°� Q Manteca 823-7104 <br /> Final Inspection by Date for. O/oll ❑ Tracy 835-6385 <br /> Applicant f�—Adturnta'll copies to: Environmental HeRth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 5 I�-� -Z3-33 <br /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />