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4 <br /> I APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA , <br />' Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> p 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 /> I 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 � L City Lot Size pM <br /> t CJS <br /> Owner's Name 1 C Address '' ! ` ;` <br /> �. --• _-.r,...._ ... . ---"M-...-- — ,., � . `_ Phone <br /> Contractor---" " - - Address -"-" •-- _ Rn ~ License No. <br /> - Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION'"❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOS_AL`FLD. 'PROP.,LINE ; <br /> FOUNDATION AGRICULTURE'WELLOTHER WELL t PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of-Well Excavation3 <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Specifications• <br /> M Public n Other 17� Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation Approx, Depth I I Eastern Surface Seal Installed by ,r i <br /> Repair Work Done 0 Type of Pump H_p, <br /> State Work Done w <br /> Well Destruction ❑ Well DiameterSealing Material trop 50') y <br /> Depth Filler Material (Below 501 { <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION kREPAIR/ADDITION 1'I" DESTRUCTION I 1 (No septic system permitted if public Jis <br /> i t available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of livingunits: f � .. <br /> _°f _, Number of bedrooms_ <br /> Character of soil to a depth'of 3 feet:T"^^* <br /> Water table depth r <br /> ' <br /> SEPTIC TANK 0 Type/Mfg �- -" � f <br /> Capacity No. Compartments-� - { <br /> PKG. TREATMENT PLT. El <br /> t Method of Disposal # <br /> Distance to nearest: Well Zpa Foundation lOry. <br /> ..Property Line <br /> LEACHING LINE [A No. & Length of lines �b Total length/size <br /> FILTER BED ❑ Distance to nearest: Well -Foundation Property Line"' ' <br /> SEEPAGE PITS 1 1 Depth Size f Number" t, <br /> SUMPS ❑ Distance to nearest: Well €Foundation Property Line I <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. qq <br /> Home owner or licensed agent's signature certifies the following: "I certify that in Weiperformance of the work for which this permit is issued, I shall not l <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,1 shall empfoy persons subject to workman's compensa- <br /> tion laws of California." <br /> The appli:��usi coil far elf re'uimd inspections. Complete drawing on reverse side. <br /> Signed XJ <br /> Title: ' W IV pate: <br /> DEPARTMENT USE ONLY _ <br /> Application"Accepted by. ' f <br /> Date Area >� <br /> Pit or Grout Ins b' �' <br /> pection by Date Final Inspection by o` A 0 /. <br /> _ Date <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 /> FEE C s <br /> INFO AMpUNT DUE AMOUNT REMITTED RECEIVED BY <br /> SH DATE PERMIT'No• P <br /> t"EH 13-24IREV.tiKsl DL <br /> EH 14-2t1 f <br /> d <br />