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11 APPLICATION FOR PERMIT <br /> �! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEI_TON4AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> .I PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ' <br /> (Complete in Triplicate? 1 <br /> aquin Local Health District for a permit to construct and/or install the work herein described. This application i <br /> Application is hereby made to the San Jos <br /> made incompliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District, I C ti� <br /> J PM <br /> �(� <br /> City��1 Lot Size <br /> C� <br /> Job Address / r <br /> Phone <br /> �7 /nK- <br /> Owner's Name Address f�a o� Qw!O6 <br /> J1 'O Sre - <br /> V 5 Addss,% �� � License No. s Phone `3 y} <br /> Contractoreta .� " <br /> TYPE OF WELL/PUMP: ';' NEW WELL)0 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> { PUMP INSTALLATION SYSTEM REPAIR ElOTHER 13 V� <br /> DISPOSAL FLD. PROP. LINE (�1 <br /> DISTANCE TO NEAREST: SEPTIC TANK 40 0 SEWER LINES 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL- <br /> INTENDED <br /> \ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation a _ Dia. of Well Casing <br /> Open Pack ❑ Tracy Type of Casing rT<<.G. Specifications <br /> Domestic/Private S"t-_ Type of Grout Kov <br /> ❑ Public ❑ Other ❑ Delta' Depth of Grout Seal �7Ctd <br /> ' ❑ Irrigation '%%-0 Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> IE, JP H.P. / wl" State Work Done <br /> Weil Destruction L) Well Diameter Scaling Material {top 50'1 <br /> i Depth Filler Material (Below 50'). F <br /> ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ aNailablelwitsystem <br /> ne200 feet.) if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: y Number of bedrooms I depth <br /> !� character of soil to a depth of 3 feet: Water table p a <br /> SEPTIC TANK ❑ IiType/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ 1'1 <br /> itDistance.to nearest: Well Foundation Property Line <br /> � y <br /> I <br /> Total length/size <br /> LEACHING LINE ' ' [:INo. &Length of lines <br /> GProperty Line <br /> FILTER BED Ll Distance to nearest: Well Foundation <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ElI 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 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 /> I 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 shall employ persons subject to workman's compensa- <br /> tion laws of California." J <br /> The applicant must call for all req inspections. Complete drawing on reverse side. <br /> F Signed iC <br /> ilgn� Title: Date: <br /> it FOR DEPARTMENT USE ONLY ,2 <br /> Date Area <br /> t Application Accepted by <br /> Date I"l Final Inspection by <br /> Date <br /> or Grout Inspecti <br /> I � _ <br /> !i <br /> Additional Comments: <br /> ❑ 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 DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> ` <br /> EH13-24(REV.1/s5) - '- '���.-C7O 9/3- 17 Al <br /> EH 14-26 <br />