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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!1'YEAR'FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application ris 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. 1662 for well/pump and the Ryles and Regul the <br /> ions of SJoaquin <br /> cf <br /> Local Health District. <br /> /San TV��916�(7J/���� <br /> Job Address ( �/ ' City Lot Size PM <br /> Owner's Name �-- � ' 14 " Address � -Phone <br /> I <br /> Contractor Address License No. Phone 6 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r DISPOSAL FLD. PROP.. LINE - { <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial fir-:Cl Open.Bottom t I❑ Manteca Die. of Well-Excavation Dia.,of Well Casing <br /> ❑ Domestic/Private ;❑ Gravel Pack i }'D Tracy Type of Casing Specifications ,I1 <br /> 11 Public ' , 'Other' t' fT ❑ Delta Depth of Grout Seal fi Type of Grout yl <br /> 17 Irrigation _Appr'ox,'Depth; r❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Wel Destruction ❑ Well Diameter, 4 ; Sealing Material {top 50') <br /> f <br /> 'Depthl 1 Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> i _Y o available within 200 feet.) <br /> Installation will serve: Residence-IL. Commercial_ Other <br /> Numbi&'bf living units:—� Number of bedrooms 3 <br /> 3 Character of.%soil to a depth of 3 feet: - Water table depth <br /> SEPTIC TANK Type/Mfg Capacity �� No. Compartments <br /> n + <br /> " i -"- Method of Dis al <br /> PKG. TREATMENT:PLT.. ❑7�165ii'!s1�tain-Ge <br /> 3,Z�"" v � � p�l to n +rest: Well Foundation Property Line <br /> . i <br /> a 0 T tal len th/size Z f <br /> LEACHING LINE PNo. & Length of lines 9 <br /> +FILTER BED ❑ I Distance to-nearesf: Well Foundation /fl — Property Line-r� y a <br /> ,SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance.to nearest: Well Foundation, Property-Line _ r <br /> DISPOSAL PONDS ❑ <br /> III 1 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..0:, <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 /> efrlploy any person in such manner es'to become subjeet,to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "l 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 /> t,� Ir <br /> The applicant M <br /> t tail f r I req ired inspections. Complete drawing on reverse side. <br /> 'A) <br /> Date: <br /> Signed Title: � 4A <br /> i FOR DEPARTMENT USE ONLY <br /> EAPPlication Accepted by �\ Date 6-� Area 0/7 <br /> 1, <br /> PitorGrout Inspection by' Date Final Inspection by Date ��" <br /> ;Additional Comments:_ <br /> ❑ Stk 466-6761 i { ❑.Lodi 369-3621 11 Manteca 823-7104Tracy�835-6385 <br />+ Applicant- Return aH=copies to: Environmental Healt Permit/Services 1601 . Tzelton Ave., P.O. Box 2009, Stk., CAr, 95X11 <br /> IFE C <br /> NFO ;AMOUNT DUE,. AMOUNT REMITTED K RECEIVED BY DATE PERMIT'N0. <br /> + EH13-24(REV.515 5) <br /> EH 1428 <br />