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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CAS <br /> Telephone (209) 466-6781 <br /> i PERMIT EXPIRES TYEAR FROM DATE ISSUED 3 <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 City Lot Size PM <br /> _ r _ <br /> Owner ,,� <br /> 's Name2bG ,r1 frO,��a6"&2y Address Oho e-2' 7� <br /> Contract Address f�lC� V License N029���� phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME T ❑ DESTRUCTION A�– <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 10— <br /> DISTANCE <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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing UT <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i'1 Pgblic 17 Other i=1 Delta Depth',of Grout Seal Type of Grout{/� <br /> �._9P�✓� <br /> I I Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work-Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> �.. <br /> Depth Filler Material (Below 50') + , <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION L.1 DESTRUCTION i I (No septic system permitted if public sewer is O <br /> available within 200 feet.) <br /> Installation will serve: ResidenceCommercial Other �: 1 <br /> Number of living units: Number of bedrooms „M <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartmen <br /> PKG. TREATMENT PLT. ❑ e „ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of linesTotal length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundatidn Property Line <br /> SEEPAGE PITS 1 1 Depth Size Number <br /> SUMPS ❑ Distance 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 I <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 mus II for quired inspectio' Complete drawing on reverse side. <br /> a <br /> Signed X Date• <br /> ,.. FOR DEPARTiMENT USE ONLY b <br /> Application Accepted by Date_J� ���"y� f k-- Area r <br /> Pit or Grout Inspection by Date Final Inspection by /� Data �� I <br /> Additional Comments: <br /> t <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Retuln all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> FEE ` <br /> I <br /> CK 0 <br /> INFO AMOUNT RUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.I/e 5, <br /> EH 14-2e / <br />