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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HA7ELTON AVE., STOCKTON, CA PERMIT NO. <br /> Telephone (209)-466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 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 /> Job Address {V, Subdivision Name <br /> Owner's NamZIE! Phone <br /> Contractor's License No, Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT F-] DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER f� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS jf <br /> INTENDED USE TYPE OF WELL PROBLEM AREA <br /> ! 4 CONSTRUCTION SPECIFICATIONS <br /> * <br /> Industrial •Lf�Dpen-Bottom -QManteca— ' <br /> r <br /> - � -- � -Dia.-of-Well Excavation <br /> LJ Domestic/Private Gravel-Pack 0 Tracy Dia. of Well Casing <br /> Public G Others Q-Del,ta e <br /> irrigation Type of Casing <br /> V 9 A <br /> pprox. Eastern Specifications <br /> Cathodic Protection p <br /> I-]Geophysical *Depth'of Grout Seal <br /> Other 2 � F Ty_p of Grout <br /> Surface Seal Installed by <br /> Repair Work Done E] Type of Pump H.P. ^State-Work-Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') , k <br /> Depth Filler Material (BelOWL501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LL REPAIR/ADDITION J (No se.ptic;tank•:o'r seepage pit permitted if public sewer is <br /> w I <br /> Installation will serve: Residence r/� Comavailable within 200 feet.)mercial _ Other � r <br /> Number of living units: ___L Number of b drooms Lot size' <br /> Character of soil to a epth of 3' 't: f'i`r' - Water table depth <br /> SEPTIC TANKType/Mfg e Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg rCapacity+ , f Method of Disposal <br /> SEWAGE SYSTEM " '' ci. <br /> Distance to nearest: Wel undation (� ;Property Line <br /> DESTRUCTION ❑ . .I <br /> LEACHING LINE No. & lines ` .. <br /> Length- of- Total "!length/size Q �C <br /> FILTER BED Distance to nearest: Well FoundationProperty Line <br /> � F <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS FA—< Distance toknearest: Well Fou ion LQ z }Property Line <br /> DISPOSAL PONDS C� <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 fol'low'ing": "17certify,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." <br /> Contractor's hiring or sub-contracting signature certifies the following: "Icertify that in the performance of the work for which <br /> this permit is issued, I shall empioy'persons'subject to workman's compensation laws of California." <br /> The applic t must ca for al] required inspec,t.ions.• Complete drawing on reverse side. <br /> i <br /> Signed X ;_ <br /> �r�, „ Date: <br /> Title: r <br /> C] <br /> FOR AEPARTMENT USE ONLY 9 U <br /> Ap �ation�Accepted ,ryp a4Area f 2, Stk 466-6781 <br /> Additional Comments: I Lodi 369-3621 ` <br /> Pit or Grout Inspection by Date ; Manteca 823-7104 i <br /> - `"�"Find"In`spection-by - �- <br /> Dat e =_=Z_ L Tracy 835-6385.. <br /> Applicant - Return all copies to: Environmental ealth Permit/Services 1631 E. Hazelton Ave, -P.O. Box 2009; Stk., CR '45201 i <br /> FEE BASE AMOUNT DUE. AMOUNT REMITTED RECEIVEDIBY DR>E PERMIT N0. ;I <br /> .. ., ]NFO --- - - <br /> s 3D V3-� ��- I <br /> EH 13-24 REV. 10/82 10/82 SOO <br /> 14-26 <br />