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` APPLICATION FOR PERMIT { <br /> SAN JOAQUIN.LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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 /> i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for <br /> Local Health District. well/pump and the Rules and Regulations of the San Joaquin <br /> ¢ <br /> Job Address _��O , E�l�fg1 �t�f� <br /> City Lot Size PM <br /> Owner's Name C .Address <br /> f� Phone <br /> kContractor ( Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP, INSTALLATION >O' c SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINEST!— <br /> DfSPOSAL 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 - O -Manteca ---------------- <br /> Domestic/ <br /> --Well Excavation <br /> Domestic/Private ❑ Gravel.Pack Dia. of Well Casing <br /> ❑ Tracy T g � !M1 b <br /> Type of Casing Specifications ,�f�c. <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> EJ Irrigation Type of Grout <br /> --Approx. LJEastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P._ State Work Done <br /> Well Destruction` 11 Well Diameter Sealing Material (top 501) <br /> Depth p Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> tavailable within 200 feet.) <br /> Installation�irvill serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of_3 feet: t <br /> SEPTIC TANK r .<` "'` ll Water table depth f <br /> O Type/Mfg+ t Capacity No. Compartments <br /> PKG. TREATMENT PLT."❑.y <br /> t� Distance t" o`nearest: Well Method of Disposal = <br /> Foundation Property Line <br /> LEACHING LINE <br /> ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> — Number <br /> SUMPS � <br /> ❑—Distance to-nearest- --Well,:I --^w-�-• f6undati6767:�� ----+�- ..� <br /> DISPOSAL PONDS ❑ Property Line- , <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, <br /> rules and regulations of the San Joaquin Local Health District. and <br /> Home owner or licensed agent's signature certifies the following: "I certify1 <br /> -em loy an that in the performance of the work for which this permit is issu d'..I shall not <br /> p e person g such manner i to become subject to workman's compensation laws of California." Contractors hiring or sub-contractiAg 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." <br /> The applicant must all r all r d inspections. Complete drawing on reversp Ode. I <br /> Signed Title: <br /> Date: <br /> FOR DE ARTMENT USE ONLY <br /> Application Accepted by / yq / > <br /> Dat114V— 1 Area 10/1 <br /> i <br /> Pit or Grout inspection by Date Final Inspection by , Date(� <br /> Additional Comments: ) f <br /> ❑ Stk -466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546365 <br /> t <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 L <br /> FEE4 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> RECEIVED BY <br /> H 14-28 <br /> CASH DATE ;PERMI'I'N]O+EH 13-241AEV.7/951 � , � Cl <br /> E3 /. � <br />