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t <br /> " APPLICATION FOR PERMITS ✓` <br /> r�< SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA " <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1' 11 i <br /> YEAR FROM DATE ISSUED •-�� �g�"�r <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 1 <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. stM <br /> 3 S. CAUIVAZ <br /> Job Address City Lot Size PM <br /> Owner's Name Address CAR D 00 A L ' <br /> Phone <br /> /`Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 5 <br /> 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 /> D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications <br /> (-]'Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout , <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done El Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') <br /> Depth Filler Material(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I 1 DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) <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: W <br /> ater table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments \ <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line' M <br /> ' I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I ) Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line r <br /> DISPOSAL PONDS ❑ r <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 /> 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." <br /> The applicant ust call for all re uired inspec'ons. Complete drawing on reverse side. f <br /> Signed Title: M�ti- _ Date: <br /> v <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Area ( <br /> Pit or Grout Inspection b <br /> Pe y Date Fina! Inspection by Date • <br /> Additional Comments: C1 . ' <br /> ❑ Stk 466-6781 ❑ 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 /> FEE AMOUNT DUE CK <br /> INFO AMOUNT REMITTED H RECEIW BY DATE PERMIT NO. <br /> +.EH t3.2<IREV.i/n55 <br /> EH 14-2tiJL <br />