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APPLICATION FOR PERMIT L� ,?� <br /> SAN JOAQUi'1 LOCAL HEALTH DISTRICT f3� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. ,- <br /> Telephone (209) 466-6781 <br /> DATE ISSUED .2 �� <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 Re u1 ''ions of the San Joaquin Loca Health District. <br /> Job Address �O� subdivision Name <br /> Owner's Name / Address Phone �__ 0 <br /> Phone <br /> Contractor's Name <br /> License No. <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ Ifi <br /> W <br /> PUMP INSTALLATION�' SYSTEM REPAIR ❑ OTHER ❑ W i <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS W <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U` <br /> Industrial ❑ Open Bottom Manteca Dia. of Well Excavation <br /> Domestic/Private �tlGravel Pack Tracy Dia. of Well Casing <br /> ❑ Public F-jOther []Delta Type of Casing <br /> Lj Irrigation Approx. [] Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> ❑Geopnysical Type of Grout <br /> LJ Other Surface Seal Installed <br /> by <br /> Repair Work Dane [] Type of Pump H.P. State Work Done <br /> , s7 <br /> Well Destruction F-1WellDiameter Sealing Material (top 50') Y� z <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION E:1REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence — Commercial _ Other C <br /> Number of living units: Number of bedrooms Lot size (� <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK F-1 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. F-1 Type/Mfg <br /> Capacity Method of Disposal <br /> SEWAGE SYSTEMDistance 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 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 workmanS 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 issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applican t call fo all equir inspettions. Complete drawing on reverse side. <br /> Signed K <br /> .��d+7.—'Title: Date: <br /> FO DEP ENT USE ONLY Stk 466-6781 <br /> Application Accepted by Area EJ 7 ❑ <br /> Lodi 369-3621 <br /> Additional Comments: ❑ Manteca 823-7104 <br /> Pit or Grout Inspection by Date <br /> Final Inspection by <br /> Date L7 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> T ND.RMI <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PE <br /> INFO <br /> e 1 1 <br /> 10/82 500 <br /> IH 13-24 REV. 10/82 <br /> 14-26 <br />