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h APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 /> I <br /> f t <br /> k Job Address u v �' �" """ City �✓'�1 i l • Lot Size PM <br /> Owner's Name � VfX y" Address �a � - � � ` i� Phone <br /> Contractor_ <br /> �isl �i P S Address `` -+hCfi�1 License No, � 5W / hone f `O <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> 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 Dia. of Well Casing <br /> ❑,Domestic/Private ❑ Gravel Pack,,; ❑ Tracy Type of Casing Specifications <br /> I- Public ❑ Other 4 Ci Delta Depth of Grout Seal Type of Grout _ <br /> I <br /> 11I Irrigation �..Approx�.,Depth l I Eastern Surface Seal Installed by o _ : <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> { Well Destruction ❑ Well Diameter Sealing Material (top 50'1 (� <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i.].y REPAIR)ADDITION l 1 DESTRUCTION I { INo septic system permitted if public sewer is <br /> a available within 200 feet.) <br /> Installation will sere: 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 nearest: Well Foundation Property Line }r <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 Di§trict. <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 /> tidn laws of California." <br /> The applic must call for all r uired inspections. Complete drawing on <br /> erse Ide. <br /> Signed X_� Title: l� JIf�1l.f/y Date: "�l i s <br /> I <br /> JtP.ARTME=NLY <br /> I Application Accepted by Date r Area <br /> Pit rout Inspection by Ayeo9s,.�Date_ en Final spection by Date 1 <br /> Additional Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO �9 CASH y <br /> + EH 13-24 fREV.1/8 51 'f 3sV 3S f TLS / 7'5" <br /> EH 14-213 <br />