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+ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ) <br /> f 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Q <br /> Telephone (209) 466-6781 <br /> 1 � <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED DATE ISSUED V-3 <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 <br /> I Subdivision Name Y <br /> I <br /> Owner's Name _ >� Address Phone <br /> Contractor's NameLicense 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 �N <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA: CONSTRUCTION SPECIFICATIONS <br /> I Industrial a <br /> r <br /> J U Open Bottum � Manteca Dia, of Well Excavation <br /> Lf Domestic/Private Gravel Pack ❑ Tracy Dia, of Well Casing <br /> Public ❑ Other ❑ Delta <br /> _Type of Casing <br /> Ll irrigation Approx. ❑ Eastern Specifications <br /> Cathodic Protection Depth <br /> Depth of Grout Seal <br /> Geophysical <br /> LJ Other Type of Grout <br /> Surface Seal Installed by 1 <br /> Repair Work Done [J Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50`) ? <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONi REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial A( Other 60 1 <br /> Number of living units: Number of bedrooms Lot size X1 b _ <br /> Character of soil to a depth of 3 feWater table depth <br /> SEPTIC TANK Type/Mfg ,"y1 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal] -� <br /> SEWAGE SYSTEM Distance to nearest: Welloundation` Property Line_.. ` <br /> DESTRUCTION ❑ <br /> LEACHING LINE ] No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation of Property Ne, j <br /> SEEPAGE PITS [j -Depth Size (` Number / 1 <br /> SUMPS Ll.\/;Distance to nearest: Well &4.k/ Foundation d 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 j <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 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 m or r uired ftections. Complete awin on r verse side. <br /> Signed X Date: <br /> F P TME USE LY <br /> Application Accepted by Area b Z Stk 466-6781 j <br /> Additional Comments: [] Lodi 369-3621 <br /> I <br /> Pit or Grout Inspection by Date L Manteca 823-7104 <br /> Final Inspection by Date Tracy 835-6385 <br /> Applicant - Retprn all copies to; E ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 3 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> y2 Lfj <br /> b-`�f <br /> EH 13-24 REV. 10/82 10/82 50 <br /> 14-26 <br />