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r APPLICATION FOR PERMIT <br /> SAN JOAQU;N LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. <br /> Telephone (209) 466-6781, pp <br /> - DArf`ssuED i <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 he San.Joa uin,Local Health District. <br /> Job Address (PIV4912 Subdivision Na e <br /> Owner's Nam l CaE <br /> ��Add ress PhoneContractor's Nam ense No. Phone 1 IF/1?S <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR [I OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION .c AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED 6SE1 _ TYPE R WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> y ❑ Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation <br /> (❑ Domestic/Private ❑ Gravel Pack ❑Tracy Dia. of Well Casing <br /> ❑ Public Other ❑ Delta Type of Casing <br /> Irrigation Approx, ❑ Eastern Specifications <br /> ❑ Cathodic Protection Depth <br /> Depth of Grout seal <br /> ❑Geophysical Type of Grout <br /> ❑Other Surface Seal Installed by <br /> Repair Work Done Q Type of Pump H.P. State Work Done ` <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') Q <br /> Depth Filler Material (Below 50') + <br /> TYPE OF SEPTIC WORK:; NEW INSTALLATION ❑ REPAIR/ADDITION j (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will�ser`ve: Residence k Commercial Other <br /> Number of living units: _�_ Number of bedrooms Lot size �Lt ' <br /> Character of soil to depth of 3 feet: Wa';9•er table depth [�' I <br /> ✓ + <br /> SEPTIC TANK . Type/Mfg Uva— Capacity /pZ d G No. Compartments <br /> PKG, TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property�Lirae <br /> DESTRUCTION <br /> LEACHING LINE - No. & Cength of lines Q Total length/size D Z <br /> FILTER.BED { '❑ y Distance to nearest: Well S� oundation Pro perty'tine <br /> SEEPAGE PITS <br /> ,❑ Depth Size Number <br /> nearest: Well oundation roperty Line .S` <br /> SUMPS � Distance to l no I,� <br /> DISPOSAL PONDS <br /> application and that the work will be done in accordance with San Joaquin county <br /> I hereby certify that{I have prepared this app <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 /> b-c ntractin si nature certi'fi'es the foTlowin "I certify that in the performance-of-the--wopk-for which <br /> Contractor's-hiring-or su o g 9 g, <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." - >< <br /> The applicant m t call for all required inspections. Complete drawing on reverse side. <br /> Signed X - '� -Title: , . Date: �—o r { <br /> F R DEPARTMENT USE ONLY ' "A- <br /> Application Accepted'by Area-7r=;) :, _ ❑ Stk ;`. 466-5781 <br /> t Codi <br /> Additional Comments: ' 369-3621 <br /> Pit or Grout Inspectiby Data- U Manteca 823-7104 <br /> cy <br /> Final Inspection by Date 7'-Tra--- 835=6385_ <br /> Applicant - Return all copies to: Environm n al He th ermit/Services 1601 F. H zelton Ave., P.O. Box 20 9,� Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTEQ RECEIVED BY DATE r PERMIT .NO. <br /> 4 INFO (� a 13 <br /> 3 <br /> 10/82 500 <br /> f' EH 13-24 REV. 10/82 + <br /> 14-26 <br />