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,. APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Fj <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 MAR Z <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Cti�![f'Oi�lJw�3� L! FALiI� <br /> (Complete in Triplicate) PEP- MIT j SDRVICES <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 far Weill pump and the Rules and Regulati"so�San Joaquin <br /> Local Health District. <br /> x <br /> City <br /> �ry Lot Size PM <br /> V <br /> Job Address <br /> G/a/�pAddress ��+ '�' ` Phone <br /> Owner's Name �L �• <br /> /+ y <br /> i <br /> Contractor 5 ddress ' License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR__$,e,? OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [71 industrial ❑ Open Bottom D Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> /&PbType❑ Gravel Pack ❑ Tracy of Casing Specifications <br /> M Public <br /> Other (_1 Delta Depth of Grout Seal Type of Grout <br /> r { <br /> I I irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by' � o <br /> Repair Work Done ❑ �- Type of Pump H.P. I§ State Work Done <br /> Sealing Material (top 50'lr t tS !�' �� Z 7O <br /> Well Destruction ❑ Well Diameter-- 9 , <br /> Depth V - Filler.Material (Below 50') — <br /> TYPE OF SEPTIC WORK,' -NEW INSTALLATION [-I REPAIR/ADDITION ii DESTRUCTION I I (No septic system permitted if public sewer is <br /> T w available within 200 feet.) <br /> Installation will serve: Residence ` Commercial.— Other �} <br /> Number of living units: Number of bedrooms 6 <br /> Character of soil to a depth of 3 feet:+f '` Water table depth <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ TypelMfg <br /> PKG. TREATMENT PLT:P- Method of Disposal <br /> x Distance to nearest. Well Foundation Property Line _ <br /> Total length/size <br /> ° �, LEACHING LINE""-' -D—No:&Length of lines <br /> `-FILTER BED* <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 Depth Size Number — <br /> 4 <br /> SUMPS�. -��*, '`� C! Distance to nearest: Well Foundation Property Line <br /> DISPaSAL 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 <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 /> w. 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 applican requi tions. Complete drawing on reverse side. <br /> Signed X Title: '� Date: <br /> FO �DEPA ENT USE ONLY f <br /> Application Accepted by _J&� <br /> Date -� Area i <br /> Pit or Grout Inspection by r Date Final inspection by /�7?'Z Date <br /> j Additional Comments: <br /> C] Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY VASE PERMIT�NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> E . <br /> +.ER 13-24(REV,1/9 5) INFO �/ 1� <br /> EH 14-2B "T1 <br />