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APPLICATION FOR PERMIT <br /> SAN JOAN UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HLl AZELTON AVE., STOCKTON, CA ND ee<1ok�V-41 ova �IILZ <br /> Telephone (209) 466.6781,. <br /> PERMIT EXPIRES 1,YEAR FROM'DATE- ISSUED <br /> 4 ' • I �1(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.%49 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. Fa ,� <br /> t <br /> Job Address , M <br /> City of Size � PM <br /> Owner's Name _, <br /> 1 ,dess r . Y - t' <br /> . I ,, Phone <br /> � i <br /> Contractor ess XI. I 0 <br /> TYPE OF W LL PU P: NEW W LL ❑ I i se No, hone <br /> WELL REPLACEMENT ❑' DESTRUCTION 0 <br /> PUMP INSTALLATION ❑ SYST1. EM REPAIR'❑r � OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC'TANK''4, SEINER LINES t- <br /> DISPOSAL FLD. P INE <br /> �-' FOUNDATION E AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL ,` PROBLEM f REA CONSTRUCTION SPE IONS <br /> ❑ Industrial <br /> ❑ Qpen Bottom.. + ❑ Manteca Dia. of�Casing___ <br /> tion " t ` Dia. of Well Casing <br /> t ❑ Domestic/Private 11 Gravel Pack D.-Tracy-1 of❑ Public �'- Specifications <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> 1-1 Irrigation Type of Grout <br /> ---Approx. Depth astern l� Surface Seal Installed by <br /> Repair Work Done ❑ Type of P H P <br /> State Work Done s1 <br /> Well Destruction ❑ Iometer Sealing Material {top 50') <br /> Depth f Filler Material f8elow 50')' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIR/ADDITION ❑ DESTRUCTION o septic system permitt d if public sewer is <br /> available within 200 feet.) 3 <br /> Installation will serve: Residence Commer tial_ Other I ; , t-A. <br /> Number of living units: Number of bedrooms ~—~ <br /> Character of soil to a depth of 3 feet: ) 0 1 <br /> SEPTIC TANK ❑ Type/Mfg ype Water table depth 4 <br /> g Capacity No. Compartments t ; <br /> PKG. TREATMENT PLT. L2f <br /> Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line r <br /> LEACHING LINE ❑ <br /> No. & Length of lines M Total length/size 3 <br /> FILTER BED ❑ Distance to nearest: We Foundation ` <br /> _ Property Line <br /> SEEPAGE PITS ❑ Depth Size k s <br /> Number I' <br /> SUMPS ❑ Distance 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 Joe lin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District:` ; ti <br /> Home owner or licensed agent's signature certifies the followin "I e + ' <br /> J: 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 of sub-contracting signature <br /> certifies the following: "I certify that in the performance of the wkOrk for which this Permit is issued, I shall employ tion laws of California." k` P y persons subject to workman's compensa- . <br /> The applicant st for II r u'r inspections. Corgplete drawing on rse side. <br /> Signed Title: Dater <br /> R'DEPARTMENT USE ONLY <br /> Application Accepted by <br /> �� Date 22� Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK �U <br /> INFO r 'CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-244REV.tia51I� - y <br /> EH 14-28 <br />