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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. s" <br /> Job Address /� yJ~ I� Ciry Lot Size X l � PM <br /> Owner's Name�/�/Q Address Phone e-fS-- <br /> Contractor's Name �71%�lt4�.�License No:-� � �„ Phone �7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> r <br /> t 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 /> ❑ Industrial , ❑ Open Bottom ❑ Manteca _Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications <br /> ❑ Public.} 0-Other ❑ Delta Depth of Grout Seal Type of Grout <br /> El Irrigation ---Approx. Depth ❑Eastern Surface Seal Installed-by.:. <br /> Repair Work Done_ ❑. Type of Pump H.P.• 'State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 " <br /> *w :� <br /> Depth � % 'Filler Material IBelo 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION V DESTRUCTION ❑ (No septic system permitted if public sewer is N� <br /> available within 200 feet.) <br /> 'Installation will serve: Residence commercial_ Other f" <br /> Number of living,units: Number'of bedrooms <br /> Character of soil to a depth of 3 feet: r -- — F Water'table depth <br /> SEPTIC TANK ❑ Type7Mfg .,Capacity No. Compartments" - <br /> PKG. TREATMENT PLT. ❑ °` _ Method of Disposal a <br /> 4f <br /> Distance to nearest: Well A611F58 Foundation."SO_ Property,Line�14-2 <br /> LEACHING LINE 8--No. & Length of lines f 9?© � Total leng'thlsi e d <br /> FILTER BED > ❑ Distance to-nearest: 'Well Foundation Property Line <br /> -- ,.,Q....�:r.-.,�-,=-_.,R• x»--- .. ..ter <br /> SEEPAGE PITS ❑ Depth Size ) Number <br /> SUMPS f ❑ -Distance to nearest: Well. Foundation Property Line <br /> - k } <br /> DISPOSAL PONDS t ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with"San Joaquin county ordinances, state laws, and <br /> rules and regulations of the.San Joaquin Local Health District. S <br /> Home,;owner or licensed agent's,signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person-in such mariner as til become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> k <br /> The applica t"call for-all-re uire -inspections-Complete-drawing-on-rever9b-sidN <br /> SignedTitle: Date: '3 � <br /> r FOR DEPARTMENT'USE ONLY <br /> Application Accepted-by _ C% Date �' Area <br /> t <br /> Pit or Grout Inspection by y Date Final Inspection by .. Date > i <br /> i i <br /> Additional.Comments: . <br /> ❑ Stk 466-6781 LI Lodi 369-3621 ❑ Manteca 823-7104y� ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2006, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. f <br /> EH 13-241REV. 10/931 S. O r 3`"7/ T, �f..f♦�� <br /> EH 1428 � <br />