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F - <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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. <br /> Size �` P M <br /> Job Address [,�67-1 GAA � A City Lot S ze <br /> r f <br /> Owner's Name Address Phone <br /> Contractor YrtS` 9aC Address DJ License NA" Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El <br /> DESTRUCTION ❑ <br /> t _ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ' S ER LINES DISPOSAL FLD. PROP. LINE <br /> a <br /> FOUNDATION `- AG CULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 1, , ❑ Open Bottom - ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1-1 Domestic/Private L1Gravel;Pack,--x.. , LJ Tracy <br /> Type of Casing Specifications <br /> M Public Cl Other 17 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth Ii Eastern rface Seal Installed by _ _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Mate al (top 501) <br /> Depth Filler Material Blow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200.feet.I <br /> Installation will serve: Residence—,' Commercial `! Other <br /> Number of living units: Number-of bedrooms <br /> Character of soil to a depth of 3 feet: '` Water table depth <br /> 5E C TANK ❑ Type/Mfg 4 Capacity No. Compartments <br /> PKG. T ATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well ° Foundation; Property Line <br /> o�l✓�S�-�vD. . �cor2 . _ � <br /> LEACHING LINE ❑ No. & Length of lines S-- ' Total length/size <br /> FILTER BED ❑ Distance to nearest:, Well r Foundation Property Line <br /> SEEPAGE PITS I I ;Depth r Size �� Number <br /> SUMPS , C—l/¢istance 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. %. <br /> Home owner or licensed agents signature certifies the following: 1 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: "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 /> . C <br /> The applic must call for all required inspections. Complete drawing on reverse side. <br /> Signi Title: ate: �ri uV T <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ~a rf E8 Area <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369421 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED CeR1,6 RECEIVED BY DATE PERMITNO. <br /> INFO CASH <br /> EH 3-24 /� C <br /> +.EH 14 26 tREv.r i x 51 { <br /> E r� <br />