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e APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZELTON AVE.,,STOCKTON, CA <br /> l Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 q <br /> .�� .(Complete in Triplicate)1 joV6 1987 <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 appI'c n is <br /> made in compliance with.San Joaquin County Ordinance No.549 for sewage or No. 1862_ for well/pump and the Rules and Re I AftthlA Pp uin <br /> Local Health District. <br /> fps I r _ ENVIR�`-, <br /> . QERN�IT/SERVICES <br /> Job Address �lJkt� City Lot Size PM <br /> ,- <br /> i Owner's Name _-_; w Address 2c ^� <br /> Phone 3�s <br /> Contractor _ Address P / L 4 <br /> License NoPhone r <br /> L TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 4. PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO., PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Y <br /> INTENDED USE "TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br />` ❑ Irrigation --Approx. Depth . ❑ Eastern Surface Seal.Installed by <br /> Repair Work Done ❑ T f <br /> p Type of Pump� H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (tap 50') 06l <br /> Depth Filler Material (Below 50') 11� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 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: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg r Cdpacity t -4, �No. Compartments <br /> " PKG. TREATMENT PLT. ❑ Method of Disposal <br /> 557 <br /> Distance to nearest: Well Foundation r Property Line <br /> LEACHING LINE ❑ No. & Length of lines � ` •` Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> _ .. <br /> DISPOSAL PONDS ❑ --- - ._..'_� r ..- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Jo�-aquin county ordinances,-state laws, and <br /> rules and regulations of the San Joaquin Local Health pistrict. <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 subjedto workman's compensation lawsof 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 ust call s actions. Complete drawing on reverse side. <br /> Signed X Title: Date: Jf• <br /> f FOR DEPARTMENT USE ONLY <br /> Application Accepted by DateAra4n. <br /> Q <br /> Pit or Grout Inspection by Date a Final Inspection by a <br /> Additional Comments: <br /> ❑ Stk 466-6781 - ❑ Lodi 3639-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 l <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY: DATE PERMIT-NO. <br /> i <br /> r f <br /> + EH 1 <br /> 3-24(REV.s i n 5) - <br /> EH 14-26 <br />