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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 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 a San Joaquin Local Health District, <br /> Job Address Subdivision Name <br /> �^ , � �� Phone <br /> Owner's Name o2- Address w <br /> Contractor's Name ,' <br /> License Na. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR L] OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDRTION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial U Open Bottom Manteca Dia. of Well Excavation <br /> U Domestic/Private E Gravel Pack Tracy Dia. of Well Casing <br /> Public [—I Other Delta Type of Casing <br /> V Irrigation Approx. []Eastern Specifications <br /> ❑Cathodic Protection Depth Depth of Grout Seal <br /> Geophysical Type of Grout <br /> U Other Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction [1 Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION }� REPAIR/ADDITION LJ (No septic tank or seepage p1availableewithinu200cfeet.sewe) 's <br /> Installation will serve: Residence .{ Commercial _ Other <br /> Number of living units: Number of bedrooms 4 _. Lot size T=�� <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity _ _r No. Compartments <br /> SEPTIC TANK [+� Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. F-1 Type/Mfg Capacity <br /> Property Line <br /> Well <br /> SEWAGE SYSTEM Q Distance to nearest: Wel _ Foundation _ P y <br /> DESTRUCTION <br /> No. & Length of lines ~ R ,'mss Total length/size <br /> LEACHING LINE } 9 <br /> FILTER BED <br /> Distance to nearest: Well i, Foundation Property Line <br /> SEEPAGE PITS DepthSize y '' Number <br /> SUMPSLI Distance to nearest: Well / " -- Foundation Property Line <br /> DISPOSAL PONDS CV <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 workmanl; compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance 6f the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." , 3 i <br /> The applicant must call for all required inspections. Complete drawing on reverse side. Date: <br /> Signed X Title: <br /> FOR,A)EPARTMENT USE ONLY <br /> r, Area f Stk 466-6181 <br /> Application Accepted by 5Lodi 369-3621 <br /> Additional Comments: D Manteca 823-7104 <br /> Pit or Grout Inspection by Date L� <br /> Final Inspection by <br /> Date L7Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FLFEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> 10/82 500 <br /> EH 13-24 REV. 10/82 ! 4 <br /> 14-26 <br />