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061'_ 7 <br /> r APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> C 1601 E. HAZE T ON AVE., STOCKTON, CA I <br /> J <br /> Telephone (209) 466-6781 <br /> a <br /> PERMIT EXPIRES '{'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 /> I� 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 /> r <br /> Job Address/ <br /> City Lot SizeAAG� PM <br /> Owner's Na Address /Y136 S, ��`� "-" Phone <br /> ContracAddress�&/ :/� �� f License Noy _Z Phone <br /> �r����•� , ��� ��,,��'�— <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUIVIPS I ,Y <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICA710NS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation x Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing "°0<" E Specifications <br /> 1-1 Public F1 Other ❑ Delta Depth of Grout Seal '` Type of Grout <br /> I i Irrigation _..Approx. Depth l 1 Eastern Surface Seal,installed by; - <br /> i Repair Work Done ❑ Type of Pump H.P. State`Work,Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50')T <br /> Depth Material <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ DDITIa.rMf <br /> DESTRUCTION l I (Noave septicsystem permitted if public sewer is <br /> y f� available within 200 feet.) <br /> t installation will serve-- Residence_ Commercial Other 1 <br /> Number of living units: Number of be®r oms / <br /> Character of soil to a depth of 3 feet: — Water table depth LQ <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ ' Method of Disposal <br /> Distance to nearest: Well f_ Foundation Property_Line <br /> 4 °" 'f Total ien <br /> LEACHING LINE ❑ No. & Length of lines thlsize 9 <br /> FILTER BED Gl-�-.Distance-to-nearest:--.—We;;C1` - —Foundation —Property-Line <br /> SEEPAGE PITS Vit Depth, � __&ze Nrmber <br /> SUMPS —'L_,IVisiance•toynr%rest: k Well t,�� F-o.undation 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 agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l 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 /> The applican u call for quire inspections. Complete drawing on rever side. <br /> SignedTitle: Date: `� r <br /> FOR DEPARTMENT USE ONLY <br /> -Application Accepted by date t �� � . Area <br /> I Pit or Grout Inspection by Date Final inspection by Date <br /> Additional Comments: �%"�` ins 'td 24 <br /> E ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ racy 835-6386 <br /> Applicant- Reiurn'alf-copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE: AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-241REV.118 5) $�^q <br /> EH 14-2e <br /> c <br />