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? APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE:.TON 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 a 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. <br /> `7City Lot Size PM <br /> Job Address ' <br /> C��iyg,�y�2-4,�_-Address /��a'g '�� - Phone <br /> Owner's Namef <br /> 4 �T G1�r� Phon <br /> Contractor <br /> 4- Address ''` License No. <br /> TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIQN ❑ <br /> SYSTEM REPAIR <br /> PUMP INSTALLATION ❑ <br /> OTHER,❑ ' T <br /> tbISPOS <br /> SEWER LINES AL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL I e -'PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> t. <br />( INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> r Type of Casing Specifications <br /> t ❑ Domestic/Private ❑ Gravel Pack 17 Tracy Type of Grout - <br /> I'1 Public ❑ Other ❑ Delta Depth of Grout Seal <br /> I I Irrigation --Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done ''K Type of Pump <br /> H.P. L*DAe6 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 i 7 REPAIR/ADDITION l I DESTRUCTION t i availabe within 200 feetNo septic system ltled it public sewer is <br /> Installation will serve: Residence= Commercial— Other <br /> Number of living units: Number of bedrooms 3 " \ <br /> a Nl`Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments a a- <br /> -.'------ Capacity: ] w <br /> SEPTIC TANK ElType/Mfg <br /> M <br /> � ! I <br /> ,} �� �} tet,, e <br /> PKG. TREATMENT PLT, 17i 4 <br /> Distance to nearest: Well x Foundation Propertp <br /> LEACHING LINE ❑ Na. & Length of lines <br /> Total length/size I ULn1929 <br /> i{ <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> DIVIROs ME' Lt I <br /> SEEPAGE PITS 1 1 Depth Size Number ICS <br /> SUMPS 0 Distance to nearest: Well Foundation <br /> Property Li I r <br /> F 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 Di1trict. <br /> I 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, l shall not <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 /> t tion laws of California." <br /> r <br /> The applicant must II for all requi ed inspections. Complete drawing on versa si e. <br /> I Signed <br /> Title: Date• <br /> /! DEPARTMENT USE ONLY 12, _� <br /> Date rea 2A <br /> Application Accepted by <br /> Date Final Inspection by a# <br /> Pit or Grout Inspection by _ _ <br /> r <br /> Additional Comments: - -� .,�_ <br /> ❑ Stk 466-6791 ❑ Lodi r369-3 21 ❑ Makteca 823-7104 L'.1-TGcy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S1k., CA 95201 <br /> i E-A <br /> FEE ;AMOUNT OUE AMOUNT REMITTED SH RECEIVED 8Y DATE PERMIT'NO. <br /> INFO <br /> +.EH 13-24{REV.t/K 51 �D T Z <br /> EH 14.28 <br />