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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 /> 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 d Reg lations f he San oaquin Local Health District. <br /> Job Address - Subdivi ion Name <br /> Owner's Name Address cam_ <br /> Contractor's Name License No. <br /> TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION E] SYSTEM REPAIR OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ty_ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial Open Bottom ] Manteca Dia. of Well Excavation <br /> U Domestic/Private Gravel Pack Tracy Ria. of Well Casing 1 d <br /> 17 Public F-1 Other ❑ Delta <br /> Irri ation Type of Casing <br /> u g Approx. Eastern Specifications <br /> Cathodic Protection Depth Depth of Grout Seal <br /> [�Geophysical <br /> Other Type of Grout <br /> 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') _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION U (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence Commercial Other available within 200 feet.) <br /> Number of living units: Number of bedrooms` Lot size <br /> Character of soil'to a depth of 3 fe t Water table depth <br /> SEPTIC TANK [ Type/Mfg Capacity Q1Na. Compartments <br /> PKG. TREATMENT PLT, Type/Mfg f Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING_LINE Teo, No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Li.ne <br /> SEEPAGE PITS Cj Depth Size Number <br /> SUMPS IJ 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$ compensation laws of California." <br /> Contractor's hi ing 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 subject to workman's compensation laws of California." • <br /> The applica must ca d inspections. Complete dr wing on side <br /> Signed Title: Date: <br /> AR NT 0 LY <br /> Application Accepted by Area El Stk 466-6781 <br /> Additional Comments: 0 Lodi 369-3621 <br /> Pit or Grout Inspection by Date Manteca 823-7104 <br /> Final Inspection by Date r Tracy 835-6385 <br /> Applicant - Return all copies to: Environments alth 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 /> EH 13-24 REV. 10/82 10/82 500 <br /> 14-26 <br />