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i a . <br /> i APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> s <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the an 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, <br /> Job Address ' <br /> city Lot Size PM <br /> it <br /> Owner's Name dress <br /> I. Phone <br /> Contractor's Name! r. is nsk. PhAna <br /> TYPE OF WELL/PUMP: I� NEW WELL ❑ WELL REPLACEMENT ❑ 7c DESTRUCTION ❑ <br /> !� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ + <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE N; <br /> II FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYP46F WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS L4 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> I� <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy _Type of Casing Specifications <br /> 1 ..�.r«.-.w- <br /> ❑ Public i ❑ Othe� 12 Delta Depth of Grout Seal n� Type"of Grout <br /> 12 Irrigation <br /> Irrigation ._Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of. H.P. State Work Done.- <br /> Well <br /> one Well Destruction ❑ Well Diameter y Sealing Material (top 50'1 J <br /> Depth �� FillWNI'aterial 113010ZErll, <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Ur DESTRUCTION ❑ (No septic system permitted if public sewer is 9 <br /> 11 1 available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other' <br /> Number of living;units: Number of Bedrooms a <br /> Character of soil to a depth of 3ipfeet: " .! Water table depth+ ' <br /> SEPTIC TANK ❑ Type/Mfg ` Ca act <br /> Capacity. No. Compartments <br /> PKG. TREATMENT PLT. ❑ II s \ A Method_of,�I��sdli <br /> Distance to nearest: Well Foundation " P operty Line / <br /> LEACHING LINEI� Ir <br /> ,el No. & Length of lines Total length/size <br /> k <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line j <br /> ih•, <br /> K Dep#h'Ajx C Size Number <br /> ry i <br /> SUMPS Distance to nearest: Well 6 Foundation Property Line .r <br /> I hereby certify that'll have prepared this application and-that the work will be done in accordance with San Joaquin county ordinances, state laws, and f <br /> 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 permit is issued, I 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: '9 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." i <br /> Thea applicant must ca r all required in ions. Complete awing on re'Arse side. 4 r <br /> PP . <br /> Signed i! Title: <br /> Date: <br /> } FOR DEPARTMENT USE ONLY <br /> Application Accepted Date <br /> �fA a <br /> / <br /> Pit or Grout Inspect() I Date, -17q Final Inspection by Date <br /> lI pli <br /> Additional Comments: II <br /> ❑ Stk 466$781 11. ❑ Lodi 369.3621 ❑ 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 /> INFO' CASH <br /> ' AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. <br /> „ <br /> 1It+EH 1324(REV.16/831 �p <br /> EH 14.28 <br />