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APPLICATION FOR PERMIT ; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> _ 7 Telephone (209) 466-6781 <br /> E � } <br /> PERMIT EXPIRES 1 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. <br /> Job Address �sl f j) 3 City �B S Lot Size_,�, c��.� PM <br /> T IBJ <br /> ' ( ..� Address *+ Phone <br /> Owner's Name G v t <br /> Contractor` Address License No. ` &f2&Phone <br /> j TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMEWT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES <br /> 1 `: - DISPOSAL FLD- PROP. LINE �1r <br /> FOUNDATION �AGRICULTURE-WELL­:M - - OTHER WELL--PITSISUMPS 4 <br /> INTENDED USE TYPE OF WELL, /PROBLEM ARE4—CONSTRl1CTI0fi SPECIFICATIONS' <br /> ❑ Industrial E3 Open Bottom ( ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 'KDomestic/Private Gravel Pack i ❑ Tracy f"4\, Type of Casing Specifications J@ <br /> I'1 Public ❑ Other LI Delta Depth of Grout Seal 8 Type of Grout f <br /> I I irrigation _.,.Approx. Depth I I Eastern { Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump r H.P. State Work Done_ 'V <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth k Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTAL1ATION 11 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence � Commercial Other_ - � <br /> Number of living units: Number of bedrooms _­�' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ / Method of Disposal <br /> Distance to neatest: Well Foundation Property line <br /> LEACHING LINE ❑' No. & Length of lines Total length/size v <br /> r / , <br /> FILTER BED f❑ iDistance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1`i;'Depth I- Size.. - Number <br /> SUMPS ❑':Distance to nearest: Well' Foundation Property Line <br /> DISPOSAL PONDS ❑ I 4'"'"`+.,.3 <br /> 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 a San Joaquin Local Health District. <br /> Home owner or licenseagent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not r <br /> employ any person in u mar r as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following "t hify t t in th rformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Californir' <br /> The applicant must If r I req it nspections. Complete drawing on revers s' e, <br /> Signed X Title: <br /> Date: <br /> t FQR DEPART ENT USE NLY r <br /> Application Accepted by ` Date Area <br /> a J *V11Pit or Grout Inspection by Date Final Inspection by DateAdditional Comments /_x_ � <br /> ❑ Stk 466-6781 - 0 odi 389-3621 ' '3 Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVEDBY DATE PERMIT'NO. k <br /> INFO CASH <br /> _ <br /> +.EH 1324 1pE�r.1/+t 51 <br /> f' EH 14-2e 111 <br /> S <br />