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{ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E HA.ZELTON AVE.,.STOCKTON, CA <br /> Telephd,he (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 Sari 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 />% 4 <br />° Job Address 5663 R. CHEROKEE RD. City STOCKTON Lot Size 310* X 70 ,PM <br /> J <br />(i Owner's Name DOSE J. M",QDE"ZAddress 5663 E. CHEROKEE RID: Phone2 <br /> Contractor 061IJF,R (JOSE MAIZQUFZddress 5663E mTEROKEim RD, LicenseNo. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ . ,WELL EPLACEMEN DESTRUCTION El <br /> PUMP INSTALLATION ❑ STM REP IR ❑ OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />(' FOUNDATION AGRICULTURE WE OTHER WELL PITS/SUMPS <br />° INTENDED USE TYPE OF WELL PROBLEM AREA CONSACTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca 'Dia:of Wel Excavation Dia. of Well Casing <br /> t ❑ Domestic/Private . El Gravel Pack El Tracy T pe of Casin Specifications ~,w <br /> t M Public (1 Other n Delta /P. <br /> Depth of Grout eal Type of Grout _ <br /> i I I Irrigation ---Approx.'Depth <br /> l I EasternSurface Seal Installed by <br /> Repair Work Done ❑ Type of Pump State Work Done_ <br /> r - <br /> I Well Destruction ❑ Well Diameter terial (top 50')Depth rial (Below 501 _ <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION DESTRUCTION (No septic system permitted if public sewer is :. <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: 4 Number of bedrooms <br /> Character of soil to a depth of 3 feet: G Water table depth . <br />' SEPTIC TANK ❑ Type/Mfg P 'Capacity' t? 9V _ No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposrl <br /> Distance to nearest: Well Foundation '0 Property Line An <br />} M <br /> LEACHING LINE No. & Length of linesTotal length/size \11 <br /> tFILTER BED ❑ Distance to nearest: Well Foundation 2 b Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line (�1 <br /> I <br /> DISPOSAL PONDS ❑ <br /> I, 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 /> 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." f <br /> I The applica must call for all required inspections.,Complete..drawing on reverse side. <br /> Signed X (r/"�.; Title: OWNERi Date:2�22J90 <br />( <br /> DEPARTMEN�USE ONLYCA4 �] <br /> CApplication Accepted by Date `^ Area r <br /> Pit or. Grout Inspection by Date Final Inspection by Date, <br /> as <br /> Additional Comments: <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. Haielton Ave., P.O. Box 2009, Stk., CA 95201 <br />! FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO <br />! a:EH 13-24 IRE t/x 51 e'�� / 00 J -7 Y� <br /> EH 14-26 l i/ °.� <br />