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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I _ <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is he made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> r made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations cf the San Joaquin <br /> Local Health District. , <br /> Job Address �7. ��y�+ t C1ty Y1Q& T6 P Lot Size PM <br /> Owner's NamSIA1 � i c dress <br /> Phone <br /> x <br /> Contractor _-_Address- b ._PAM License-No. .Phone I&Z- _ <br /> TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT ❑�DESTRUCTION El <br /> PUMP INSTALLATION [2 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 ❑ Mantepa Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casin �r r Specifications" <br /> ❑ Public ❑ Other { <br /> r ❑ Delta , Depth of Grout Seal .Type of Grout <br /> L-1 Irrigation —Approx. Depth ❑ Eastern '` Surface Seal Installed by "'i •' <br /> Repair Work Done ❑ Type of Pumpi H.P. State Work Done I <br /> Oc <br /> Well Destruction = <br /> ❑ Well DiameterSealing Material Itop 50'} (Atom1-41 1 <br /> r Depth j Filter Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permi71,c sewer is <br /> f available within 200 feetI <br /> Installation will serve: Residence_i Commercial— Other 'F ! <br /> r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ""° `�- —^^- ''er table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ a Method of Disposal <br /> Distance to <br /> nearest: Well oundation Property Line <br /> LEACHING LINE ❑ No. & Length of lin Total length/size <br /> FILTER BED ❑ Distance to <br /> rest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance totrtearest: 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 Joaquin county ordinances, state laws, and G <br /> rules and regulations of the San Joaquin Local Health District "" - -• - tr - - -- <br /> Home owner or licensed agent's signature'certifies the followin �. w i <br /> g: "I ce rtify that in the performance of the work for which this permit is issued, I shall not <br /> employ any r on in such manner as to tiecome subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the oli wing: "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 o C ifornia." <br /> The applica ust call qui r in ctio . Complete drawing on reverse std <br /> Signedr_ <br /> - .. Title: Date: v F <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ✓ -7 Area <br /> Pit or Grout Inspection by Date Final In <br /> I specUon by Date <br /> Additional Comments: ! 1 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.638 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 <br /> a <br /> FEE <br /> f <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT'NO, <br /> + EH 13-24(REV. <br /> EM W28 ✓ <br />�ZL <br />