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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r Y <br /> 1601 E. HAZELTON AVE., STOCKTON, CA �4, k <br /> Telephone (209) 466-6781 '+�r <br /> PERMIT EXPIRES '!'YEAR FROM DATE ISSUED y; `( h C ' <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 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 /> Job Address �r? SCC/��e 13� City Lot Size PM <br /> Owner's Name ���ffAAL— Address l f�?sem C'P (c' Phone <br /> GontractoF / - Address �� �-�S Li ense No.���'�' Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL-REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR LA, 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 /> Njndustnal ❑ Open Bottom ❑ Manteca Dia.of.Wel[,Excavation Dia. of Well Casing <br /> .-Y_- r. x <br /> f(�Domestic/Private ❑--,-Graver.Pack' """r❑-Tracy—Type-of-Casing�-�"`""�'"' �� pEcificatioils <br /> (` Public ❑ Other ! ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation ---Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done Type of.Pump H.P. State Work Done <br /> Well Destruction ❑J -.WellTDiameter Sealing Material [top 501 <br /> 1� <br /> Depth i Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence___w- Commercial__Y__. 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 Capacity No. Compartments <br /> ­PKG-"TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well oundation Property Line t <br /> LEACHING LINE ❑ No- & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest:; Well Foundation; Property Line j <br /> SEEPAGE PITS l 1 Depth Size Number <br /> SUMPS LlDistance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 Di§trict. <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." <br /> The applicant must cell for all req predanspections. Complete drawing on reverse side. <br /> Q Q�Ca <br /> Signed X� f _ Title: Date: <br /> F. DEPARTMENT USE ONLY ;,,, ty l <br /> Application Accepted by Date A Area <br /> Pit or Grout Inspection by Date Final Inspection by y1L 'r.. . . ._._ Data <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-711044 _ �a❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services,1601-E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 00FEEd <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. <br /> +.EH 13-24IREV.t/95) 15/ <br /> EH 11-18 1 <br />