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fi <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIt; LOCAL HEALTH OiSTRICT <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 /> i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein 1 <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 �, Subdivision Name <br /> Owner's Name Address _�� s�� ,fad �,� S� Phone �� Sr <br /> 'Contractor's Name J, License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIONSYSTEM REPAIR ❑ OTHER- ❑ <br /> ~DISTANCE TO NEAREST: SEPTIC TANK -4 0 '� SEWER LINES DISPOSAL FLD.'\. PROP. LINE ' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom Manteca Dia, of Well Excavation �✓ r <br /> N'Domestic/Private Gravel Pack ❑ Tracy Dia. of Well Casing <br /> ❑ Public ❑Other ❑ Delta <br /> irrigation Type of Casing ��C �,�Q <br /> I� g Approx. ❑ Eastern <br /> [�Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> ❑ <br /> Type of Grout <br /> LJ Other <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 50') _ E <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 /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial Other <br /> Number of living units: Number of bedrooms T Lot size <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK F€ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal <br /> SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line <br /> DESTRUCTION <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <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 6ertify that- ih'the performance of the work for which tris <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: "I certify that in the performance of the work for which <br /> this permit is is ued, I shall empl y p rsons subject to workman-s'compensation laws of California." <br /> The applicant a al ns, Complete-drawrse side. <br /> Signed X Title _ Date: <br /> v F D TMENT SE ONLY <br /> Appli a.i Accepted by r Arek 466-6781 <br /> Additional Comments:, - u ❑ Lodi 369-3621 <br /> Pit or Grout Inspection byDate '❑ Manteca 823-7104 <br /> Final Inspection by_, `` DateL7Tracy 835-6385 <br /> Applicant -.Return all copies to: Environmental Health Permit/Services 1601 �el 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/B2 500 <br /> 14-26 <br />