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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N01 <br /> . <br /> Telephone (209) 466-fi781 S. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED 3 AL1 <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 the San Joaquin Local�Health District. <br /> Job Address + ( fG$�division Name <br /> Owner's Narne Address Phone <br /> Contractor's <br /> Contractor's Name ( �N(t� ,, License No. _� 2/ _ Phone ��� 5 <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT 17 DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER U <br /> DISTANCE TO NEAREST: SEPTIC TANK __T <br /> WER LI DISPOSAL FLO. PROP. LINE _ <br /> FOUNDATION ZICULTURE fEL7 OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( <br /> l industrial_ ,�. ���U///Open.,Bottom _ . Q-Manteca . . Dia.•of Well .Excavation 1r' ' Ci <br /> Domestic/Private ;ravel PackTracy Dia. of Well Casing (�� ►�_ -J <br /> �]-public ( 1 Other �beIta Type of Casing a 19t S) <br /> O irrigation &a DepthSpecifications <br /> x E]Eastern � 19 <br /> Cathodic Protection P 1 <br /> Geophysical Depth of Grout Seal <br /> [J Other Type of Grout ypol A,,;0.0 <br /> Surface Seal Installed by rr/r4.,IiyP6_- ,5 <br /> Type of Pump N.P. State Work Done <br /> Repair Work Dane El <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) G <br /> Installation will serve: Residence _ Commercial Other ! <br /> Number of living units: Number of bedrooms A Lot size <br /> Character of soil to a depth of 3 feet: Water table depth O <br /> SEPTIC TANK [] Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, F_� Type/Mfg Capacity Method of 'Disposal <br /> SEWAGE SYSTEMDistance to nearest: Well Foundation Property Line <br /> DESTRUCTION C] <br /> LEACHING LINE U No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUM P� Distance to nearest- 'Weff —-- -Foundation Property-Line-'` <br /> I <br /> DISPOSAL PONDS �) j <br /> 1 hereby certify that 1 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 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 issued, I shall employ persons subject to workman's compensation laws of California." i <br /> The applican +75t'cal7 r al re ired inspections. Complete dra g or. reverse side. <br /> Signed X Title: Date: l <br /> Application Accepted FOR A N ONLY by Area �_ — ❑ Stk 466-6781 <br /> Additional Comments Lodi 369-3621 <br /> Pit or Grout Inspktlon by go Date--?-- <br /> Manteca 823-7104 <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant -.Return all copies to,: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECE:VEO BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 REV. 10/82 10/82 50C <br /> 14-'26 <br />