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APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL: HEALTH DISTRICT <br /> 1601 E. HAZEL—1 ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complefe in Triplicate) " <br /> hcation is <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 app` <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weil/pump and the R41es and Saguia�tanspf,the San Joaquin <br /> Local Health District. �L��f <br /> 1<3 City Lot Size i <br /> Job Address ,• ,. -r } <br /> di ressPhone <br /> Owner's Name "ti t, <br /> Contractor <br /> ddress ���� License No J Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C3 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 13 <br /> "R DISPOSAL FLD. PROP.'LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> J FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> , Open <br /> l <br /> INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> El Industrial ❑ Open Bottom ❑ Manteca t,—/ Dia. of Well Excavation <br /> Specifications <br /> Domestic/PflVate� D Gravel Pack ❑ Tracy ,�� Type of Casing Type of <br /> `C Public Grout— <br /> El Other El Delta �'r Depth of Grout Seal <br /> ❑ Irrigation --Approx. Depth . Eastern C.y ( Surface Seal Installed by <br /> 1 Repair Work Done [i Type of Pum J <br /> H p::r State or ne <br /> Well Destruction ❑"Well Diameter _ S 1..� Material (top 50'1 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR DDITION ❑ DESTRUCTION ❑ available septic sytem P <br /> ithin 200 feetltled 1 public sewer is <br />{ Installation will serve: Residence_ Commercial Other <br /> 1 <br /> Number of living units: Number of bedrooms j _ <br /> w ' ' <br /> ff Character of soil to a depth of 3 feet: . Water table depth; <br /> ❑ Type/Mfg <br /> - �- /- Capacity No. Compartments <br /> SEPTIC TANK <br /> --'�. �.,j Method of Disposal <br /> PKG. TREATMENT PLT. ❑ ` r <br /> "Well�_ — Fo ridation Property Line <br /> Distance-to-nearest: f E. <br /> Total length/size <br /> LEACHING LINE ❑ No. "& Length of lines <br /> FILTER BED\, ❑ Distance to nearest: Well Foundation Property Line <br /> ( <br /> SEEPAGE PITS 1--1Depth # Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ c' <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 /> EE Home owner or licensed agent's signature certifies the-following:-"I certify that in the perform-dfil a of,ihe work.for"which this permit is issued, I shall not <br /> i o become subject to workman's compensation laws of California.%,,Cositractor's hiring or sub-contracting signature <br /> employ any person in such manner as t <br /> x 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 /> 1 The applicant ust call or all required inspectio s. Complete drawing on r verse sid /J <br /> I Signed ' <br /> Title: bate: v <br /> FOR DEPARTMENT USE ONLY <br /> Date �-T�4 Area gg / <br /> Application Accepted by pate <br /> } Date Final Inspection by <br /> Pit or Grout Inspection by <br /> - Additional Comments: <br /> ❑ Stk 466-6781 , Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 55201 <br /> ffE9 <br /> K RECEIVED BY DATE PERMIT'NO. <br /> DUE ' AMOUNT REMITTED ]CASH <br /> +EH.13-24(REN.t/8 51Q -1 l0 - `ys ~`�b <br /> �wq <br /> EH 1428 <br />