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5 <br /> } <br /> APPLICATION FOR-PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED. <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.. r-...�: r , a <br /> Job Address ' City .Lot Size 6irj XLapm <br /> 1. _ Address —�/.Y' �!/J�r_,.G <br /> Owner's Name, Phone <br /> eA <br /> 77- <br /> Contractor's Name /7'C� 7 <br /> .S' License No. . �l f r _ Phone 3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION M <br /> '1 PUMP INSTALLATION ❑ ` SYSTEM REPAIR ❑ OTHER ❑ <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 ' pia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other, El Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ElEastern Surface Seal Installed by I <br /> Repair Work Done ❑ Type'of Pump H.P. State Work.Done I <br /> j <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth <br /> -� Filler Materia Be w 50') # <br /> TYPE OF SEPTIC WORK: NEW iNSTALLATION,❑ REPAIR/ADIJITIN DESTRUCTION EliNo septic system permitted if public sewer is <br /> i �_ �. available within 200 feet.) <br /> 01 <br /> Installation will serve: Residence f V f Comniercial Other . <br /> Number of living units: Number of bedrooms <br /> Character ofet. <br /> ,soil to a depth of 3 fe ` - " Water table depths <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> a <br /> PKG. TREATMENT'PLT. ❑ ?�. / Method of Disposal <br /> Distance to nearest: Well Foundation'""" Property Line s <br /> LEACHING LINE } No. & Length of lines '4 Tatal"length/size <br /> 'FILTER BED C] Distance to nearest: Well Foundation=rte Property Line ' <br /> ,o� l0 o� Number <br /> SEEPAGE PITS ❑ Depth Size - { <br /> SUMPSf 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 inlaccordance with San Joaquincounty ordinances, state laws, and <br /> rules and regulations of the San Jopquin-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 shell employ persons subject to workman's compensa- <br /> tion laws of California." ` <br /> The applicant muca r all required inspections. mplete drawing on reverse side <br /> l <br /> Signed Title: Date: <br /> FOR DEPARTMENT'USEbNLY + <br /> Application Accepted by Date G- l7 Area ' <br /> # <br /> Grout Inspection by 3� �-- - Date r �7`K Final Inspection by �' Date <br /> ���---- -� .� �- <br /> Additional Comments: <br /> E ❑ Stk- 466-6781 - ❑ Lodi 369-3621 ❑ Manteca 823-7104 - ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1fi01 E. Hazelton Ave., P.O. Box 2009, Stk.;CA 95201 <br /> I r � <br /> AMOUNT DUE AMOUNT REMITTED SCK RECEIVED BY DATE'S M YERMIT'NO. <br /> INFO <br /> + EEH 13-24 H 1428(REV.10/83) <br /> 1 V / <br />