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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 and Regulations of the San Joaquin Local Health District. <br /> Job Address Subdivision Name <br /> Owner's Name Address <br /> Phone <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION <br /> ---=,PUMP INSTALLATION SYSTEM REPAIR - OTHER _ <br /> DISTANCE TO.NEAREST: SEPTIC TANK 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 /> 17 lndaYrial U Open Bottom E Manteca <br /> Dia. of Well Excavation <br /> L} Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing <br /> Public �jOther [] Delta <br /> V IrrigationType of Casing <br /> Approx. � Eastern <br /> Cathodic Protection Depth ( Specifications <br /> Geophysical - Depth of Grout Seal <br /> U Other - W. TYpe"�"of'Grout' ` <br /> Surface Seal Installed by <br /> Repair Work Done F] Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is `f <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial _ Other <br /> Number of living units: Number of bedrooms Lot size <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC--T-ANK-- - [j Type/Mfg Capacity p Y 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 U No. & Length of lines Total length/size <br /> FILTER BED . Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS CI Depth size Number <br /> SUMPS 7 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS C� <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 performanceofthe 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 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 applicant must call for all required inspections: -Complete-drawing-on reverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Area Stk 466-6781 <br /> Additional Comments: F-1 Lodi 369-3621 <br /> Pit or Grout Inspection by Date t F� Manteca 823-7104 <br /> Final Inspection by 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 /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATEPERMIT NO. <br /> INFO <br /> EH 13-24 RSV.--10/9,2 10/82 500 <br /> 14-26 <br />