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'+ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ���: \"N Q� <br /> 1601•E. HAZE_LTON AVE., STOCKTON, CA + <br /> Telephone (209) 466-6781 , <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f <br /> t... (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 of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 4{ <br /> A r <br /> r <br /> City Lot Size PM <br /> i Job Address <br /> Phone <br /> Owner's Name / ress <br /> 21 <br /> Contractor <br /> Address ' License No. J Phone <br /> TYPE OF WELL/PUM.i: r _NEWWELL_U_�-------�W,.ELL.REP.LACEMENT❑ -DESTRUCTION-0•W--- } <br /> PUMP INSTALLATION ElSYSTEM REPAIR 13OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL l PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ,A' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1� i T of Casin Specifications <br /> i ❑ Domestic/Private 1 ❑ Gravel Pack { ❑ Tracy Type 9 t <br /> ❑ Other ❑ Delta Depth of Grout Seal x f Type of Grout <br /> 1-1 Public (-,j f t <br /> ❑ Irrigation ya ---Approx. Depth ❑ Eastern Surface Seal Installed by k <br /> H p � i-,,, State W roro k�Done I <br /> Repair Work Done ❑'I Type of Pump <br /> Well Destruction 01 Well Diameter ' Sealing Material (top 501' <br /> I �'+ Filler Material (Below 50'1 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDykU <br /> CTION (No septic system permi if public sewer is <br /> available within 2 feet.( <br /> Installation will serve:.r Residence_ Commercial_ her <br /> Number of living units: Number of bedrooms <br /> �- <br /> titer table depth <br /> Character of soil to a depth of 3 feet: t <br /> SEPTIC}TANK LTO Type/Mfg <br /> apacity No'Compartments <br /> I Method of Disposal <br /> PKG. TREATMENT PLT. ❑ r <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE El No. & Length of lines Total length/size <br /> m ' <br /> FILTER BED ❑ Distance to nearest: Well foundation � Property,.L,_,e., _._. 3 <br /> SEEPAGE PITS ❑ Depth Size Number § <br /> 3 <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line� €- <br /> DISPOSAL PONDS c� ❑ � <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 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 /> r 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' compensa- <br /> tion laws of California." ' <br /> ..~ ; <br /> The applicant must caLfall req 'red inspections. Complete drawing on reverse side.Signed Title: Data: <br /> 3 <br /> FOR'DEPARTMENT USE ONLY <br /> � <br /> real <br /> ,0 <br /> Application Accepted py.. Date } <br /> Pit or Grout Inspection by Date Final Inspection by <br /> " Date <br /> } 6 4 tl <br /> Additional Comments: <br /> Stk 468$181 ❑ Lodi 3621 EDa''"` <br /> Mantec823-710- -D'Tiacy" i5 631 1 <br /> Applicant- Return all copies to: Environmental Health Permit/5ervices"1601,E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> a <br /> FEE AMOUNT , AMOUNT-REMITTED Y ..CASH b� .RECENED,BY DATE PERMIT NO..,� .... <br /> -INFO' '""_.' � <br /> ( + EH 13-24 TREY.i 1 H 57 <br /> EH 14-28 3 <br />