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4 , <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1501 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 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 /> k Job Address 'Subdivision Name <br /> Owner's Name � A ,s Address Phone ,' »-� �L <br /> Contractor's Name License No, Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION {❑ SYSTEM REPAIR ❑ OTHER ❑•y <br /> E DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP: LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> s 'V <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d r O <br /> Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation ' <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing ' <br /> Public Other Delta <br /> E� ❑ ❑ Type of Casing <br /> Irrigation Approx. Eastern Specifications <br /> Cathodic Protection Depth <br /> i ❑ Depth of Grout Seal <br /> Geophysical Type of Grout <br /> ❑other Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump N.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Ar Depth — Filler Material (Below 50') <br /> U <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION XJ (No septic tank or seepage pit permitted if public sewer is —� <br /> ...��, 4 u available within 200 feet.) <br /> Installation will serve: Residence X Commercial Other <br /> Number of living units: � Number of bedrooms - Lot size s j <br /> Character of soil to a depth'of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg + Capacity _ No. compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> OF <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation _ Property Line _/® <br /> DESTRUCTION L�- <br /> LEACHING LINE No. & Length of lines n-' Total length/size <br /> Property <br /> FILTER BED ❑ Distance to nearest: Well Foundation �j erty Line- p �— <br /> SEEPAGE PITS ❑ Depth Size { Number <br />` SUMPS Distance to nearest: Well Foundation Property Line <br /> 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 /> 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 i compensation laws DfiCalifornia."• <br /> Contractor's hi ng or sub-contracting signature certifies the following: "I certify that in the performance of the'work for which <br /> this permit is sued, I shall employ persons ubject'to workman's compensation laws of California." <br /> The applican call f all re t� i cti ns. Compl $e on reverse side. 4 <br /> Signed <br /> Title: Date: <br /> OR DEPARTMENT USE ONLY # }I <br /> Application Accepted y Area �►Ttk 456-6781 ; <br /> m Lodi 369-3621 r <br /> Additional Comments: - <br /> C Pit or Grout Inspection Date ' ❑ Manteca 823-7104 <br /> Final Inspection by Date ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: ,Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> =BASEd .75 AMOUNT DUE AMOUNT REMITTED RECEIVED BYDATE PERMIT ND.d <br /> k ; • 10/82 So <br /> EH 13-24 REV. 10/82 <br /> 14-26 <br />