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rGr <br /> !r; APPLICATION FOR PERMIT <br /> 1 a y a Fl , <br /> J� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i <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 S?J_,t1 e c c-IAO- City"'/ar >' Lot Size PM <br /> Owner's Name 9 Address C- �� it Phone 05PV" <br /> License No. x,4O Phone <br /> - fContractor AddressI �f � 1 &• <br /> TYPE r <br /> OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR Cl OTHER I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURESWELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> A Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 17 Public ❑ Other „ ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I 1 Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done $1. Type of Pump H.P. f_ _ State Work Done 1 .0 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> 6 <br /> a <br /> Depth F Filler Material Melow 50') z49 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUC ION l I Wo septic system permitted if public sewer is <br /> T available within 200 feet.) G <br /> Installation will serve: Residence_ Commercial Other I <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 {Q <br /> PKG. TREATMENT PLT. ❑ f' Method of Disposal I 1 <br /> Distance to nearest: Well. . Foundation 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 I 1 Depth Size Number <br /> SUMPS Ll;:ZDistance to nearest: 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 <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." <br /> The applicant must 11 for all required inspections. Complete drawing on rev rsa side. f <br /> Signed X Z_tn !" _,. Title: �'�L' _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date rea <br /> �] <br /> 7 � A �C <br /> Pit or Grout Inspection by Date Final Inspection b Oat�G� <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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO <br /> FEE CASH DUE AMOUNT REMITTED CAS/HJ��/��I RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13.24 1REV.e i H sl 35 �S 4f fa��� 85 ZS-7 <br /> EH 14-26 4f 1 I <br />