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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Otto- <br /> 1601 <br /> E. HAZELTON AVE., STOCKTON, CA PERMIT NO. '3 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED:!� <br /> a <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 RegUlati of the San Joaquin Local Health District. <br /> Job Address Subdivision Name <br /> Owner's Name Address E' Phone <br /> Contractor's License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ W <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER {� w <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES1 <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! <br /> ❑ Industrial _j Open Bottom Manteca <br /> I ❑ Dia, of Well Excavation <br /> ❑ DolImestic/Private Q Gravel Pack Trac i <br /> 17PUblic ❑ y Dia. of Well Casing � <br /> I �j Other Delta <br /> F-1Ilrigation i Approx. ❑ Eastern Type of Casing <br /> Cathodic Protection Depth ;Specifications <br /> ❑Geophysicalj Depth of Grout Seal <br /> LJ Other Type of Grout <br /> Surface Seal Installed by <br /> RepairiWork Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction U Well Diameter Sealing Material (top 501) j <br /> Depth Filler Material (Belo.w_500_ <br /> TYPE bF SEPTIC WORK: NEW INSTALLATION TJ REPAI DD TION I (No a is tank or seepage t <br /> � ly ���� pi permitted if public sewer is <br /> Installation will serve: Residence _X Commercial _ Other - available within 200 feet.) <br /> Number of riving units: Number of bedrooms _C_ Lot size <br /> Character of soil to a depth of 3 feet: Water table depth , go r i <br /> J� w <br /> SEPTIC TANK Type/Mfg 1pii�t. Q/ d Capacity <br /> PKG. 7REATMENT PLT. teNo. Compartments <br /> pe/Mfg <br /> Capacity ,Method of Disposal - <br /> Distance to nearest: Weli ­ p Foundation ` Z / Property Line ` <br /> LEACHING LINE No.; & Length of lines a — �Q� Total length/size / <br /> FILTER BED i <br /> (� Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth S Size Number <br /> SUMPS ❑ Distance to nearest: WellFoundation Property Line ' <br /> DISPOSAL PONOS F] ,� � f�1 -•�''� ---•�-�--r' <br /> I hereby certify that I have <br /> ordinances, state laws, and prepared this application and that the work will be done`in accordance with San Joaquin county <br /> -rules and regulations of the San Joaquin Local Health District. <br /> Home owner or Iicensediagent':s signature certifies the following: "I certify that in-the performance of the work for which this <br /> permitlis issued, I shall not'employ any person in such manner as to become subjec-t to'workman� compensation laws of California." <br /> Contractor's hiring or sumntract ing signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is issued, I shall. employ persons subject,to-workman's-compensation laws of-California." <br /> The apblicant must call for all r ired inspe tions. Complete dra g on reverse side. �� <br /> Signed X <br /> Title: Date: .5 --�� <br /> DEP NT U E ONLY <br /> Application Accepted by Area �y��y� ❑ Stk 466-6781 , <br /> Additional Comments: / 7 '- ❑ Lodi 369-3621 <br /> Pit or Grout Inspection by �Zjl, Pfs � Cate T /7 Q Manteca 823-7104 <br /> Final Inspection by � - Date '7 ❑ Tracy 835-6385 <br /> Applicant - Return all copies:to: Environmental HeaIth_Perm.i-t/Services 16 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> J, <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIVED BY DATE PERMIT N0. <br /> s �- <br /> EH 13-24 REV. 10/82 �af <br /> 14-26 10/82 500 <br /> I <br />