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s- <br /> 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 S � <br /> zx (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 F <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.'f%` ' <br /> Job Address <br /> lr City Lot Size Y a PM <br /> Owne3 O gd y(.er's Name Addres (�one y_ y <br /> r <br /> Contractdk-� ,�.,�� 11 ' I <br /> Address P.o ( �.11 � License No, a (n a Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER a] 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS k <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 /> } ❑ Public ❑ Other ❑ DeltaL Depth of Grout Seal Type`of Grout i <br /> 11 Irrigation �Approx. Depth ❑ Eastern Cit. Surface Seal Installed by <br /> Repair_W ❑ <br /> ork,DoneTType_of-P-ump H.P. �`t -State-Work-Done--= <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR ADDITION DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> Installation will serve: Residence Coavailable within 200 feet.) <br /> mmercial_ Other <br /> Number of living units:__[_ Number,of,be roo s t <br /> -75 <br /> Character of soil to a depth of 3 feet: ' _ + Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> PKG.'TREATMENT PLT. ❑ <br /> �, ­—Method of Disposal;� <br /> v - Distance to nearest: ?Well ^ ` Foundation c + Property Line <br /> r ` k. L i <br /> LEACHING LINE @�No. & Length of lines Total Ie gth/sixes y0 1C` <br /> FI LTER 11YED ❑ -Distance to'nearest: WellO <br /> r , <br /> n = 1 Foundation ' r-(OR.,r Property Line 1fOr ' <br /> SEEPAGE PETS Depth Y Size .y� `t � Numbers <br /> SUMPS /LJ Distance to nearest:. , Well_106 Foundation <br /> — Property Line <br /> DISPOSAL PONDS/ ❑ " F - <br /> i hereby certify thit I have prepared this applicationiand that the work-will-be-done-in accordance with San'jgaquin county ordinances, state laws, and <br /> rules:and regulations of the San Joaquin Local Health District. <br /> Home owner dr licensed agenYssigriature certifies the•following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any:persamirr such manner alio become sua W to workman's compensationAws of-California."Contractor's hiring or sub-contracting signature <br /> certifies the-following: "I certify that employ persons;intthe performance of the work for which this permit is issued, i shall lons subject to workman's compensa- <br /> tion lawssof California.' <br /> The appli a_nt mus callfor;all r uirrf inspections. Complete_drawing an reverse side. <br /> Signed X Titley ' - <br /> Date: M- <br /> FOR DEPARTMENT USE ONLY ^� t <br /> Application -o�� <br /> tion Accepted by f Date Area <br /> .. ��� `'fid-��=�'� •� / - ; <br /> Pit or Grout Inspection by Dete �� <br /> { Final Inspection by Date <br /> Additional Comments: C) ` � a I <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 .❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental-Haelth Pe`Emit/.Services,1601'0-H areltiiri;Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK <br /> } <br /> INFO CASH RECEIVED BY DATE ; PERMIT NO. <br /> + EH 13-24(REV. ��� / - <br /> EH 14-26 .. .. `-6 1 �iF�� >i <br />