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I <br /> 14� APPLICATION FOR PERMIT f V D <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 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. 11362 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.. <br /> Job Address �1 O t) �1�' [ ��✓ CityESCALof Size PM <br /> Owner's Name LO�� Address + ` CA [ PB Phone <br /> ContractoQZffiC&61ZW?Address p �`f tie, z� License No.M� Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-)< DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑, <br /> DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES tt� DISPOSAL FLD.'f d PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 90-0 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 /> I/Domestic/Private /Gravel Pack ❑ Tracy Type of Casing _P111-7 — EV Specifications ,0&V-F5(e0 <br /> I-1 Public ❑ Other ❑ Delta Depth of Grout Seal �� Type of GroutASEIOIOWrC <br /> I I Irrigation 1'-Z 2-Approx, Depth I ] 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 <br /> Depth Filler Material (Below 50'x- . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial _ Other I x <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> I <br /> -SEPTIC.TANK ❑ Type/Mfg Capacity- No. Compartments <br /> t - i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> t Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE µ❑ No. & Length of lines Total length/size - t <br /> FILTER BED ❑ Distance to nearest: Well Foundation h Property Line <br /> SEEPAGE PITS I 1 Depth Size Number r <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 ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. I <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 I <br /> employ any person in such manner as to 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 ifornia.:' ' I <br /> The %plicant ustcalf all r fired inspection . Complete drawing on r verse si Signa Title: - Date: <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Application Accepted by` Date S� Area <br /> i <br /> Pit or Grout Inspection, by Date Final Inspection by Date <br /> Additional Comments: i <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ 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 /> I <br /> PEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24 <br /> + EH14-2afREV.tiH51 V Z(-,) <br /> ­--� <br />