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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (20.9):466-6781 <br /> k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t Application is hereby made to the San Joaquin Local Health District for a permit to construct and/ t he work ern described. This application 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 Joa urn <br /> tr Local Health District. Pp on is <br /> 0!© 1.t1• v£�,Tt S T, q <br /> Job Address <br /> _ City Lot Size i <br /> PM <br /> Owrier's Namefttt_sz��d <br /> PhoneContractor's Name . ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ Phone <br /> WELL REPLACEMENT ❑ 1_7 ;t <br /> PUMP INSTALLATION ❑ DES7RUCTfON ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR [IOTHER L]SEWER-LINES — DISPOSAL FLD. ; <br /> FOUNDATION AGRICULTURE WELL PROP.,, LINE 1 <br /> OTHER WELL <br /> INTENDED USE t,y: .-,TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS; �r, PITS/SUMPS <br /> ❑ Industrial _,.❑ Open..Bottom Q <br /> -_.�"°^ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑_Gravel Pack ❑ Tracy T Dia• of Weil Casing i <br /> ❑ Public; r wR ❑ Other YPe of Casing Specifications <br /> 1 ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation Type of Grout <br /> I r }. —Approx. Depth ❑ Eastern Surface Seal Installed b <br /> Repair Work Done ! ❑ Type of:Pump H p Sealing Material (tap 50') <br /> � <br /> yT <br /> Done State Work De (' <br /> Well Destruction ❑ Well Diameter , <br /> . ' 4 <br /> ` Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW 11111STALL14TION <br /> `REPAIR/ADDITION ❑ DESTRUCTION;❑ (No septic system permitted if Public �j <br /> : f` '1 <br /> available within 200 feet.! P sewer is ` <br /> t Instalation will seine: Residence_ Commarcia <br /> Othe <br /> Number of living units: � Number of bedr oms <br /> Character of soil to a depth fB feet: £ t <br /> SEPTIC TANK Type/Mfg �` Water table depth <br /> PKG�.TREATMENT PLT. ❑ ` Capacity o. Compartments ' <br /> * Methodof 9pbsal <br /> Property <br /> f Distance to nearest: Well Foundation i s <br /> { �� Line <br /> LEACHING LINE Length of lines�� C <br /> FILTER BED _Distance to nearest: Well/�j'� �, to ength/size <br /> r"' Foundation Property Line <br /> SEEPAGE.PITS ❑ 'A#pth <br /> Size Number <br /> SUMPS �. +0-t,1�1stance to nearest: Well <br /> DISPOSAL PONDS ❑ s Foundation Property Line <br /> hereby certify that 11have 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. t <br /> Home owner 6r licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued f 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-cohtracting signature <br /> tion laws <br /> fCaoforni"I certify that in the rtormance of the work for which this permit is issued, I shall employ <br /> tion laws;of California." P <br /> A Y Persons subject to workman's compensa- <br /> The applicant must cal.for all required ins actions. Complete drawing on reverse side, <br /> Signed . <br /> Title: le <br /> � s , <br /> Date; •� <br /> FOR DEPARTMENT USE ONLY d <br /> Application Accepted,by `� ' <br /> y 14 CA Date' Area <br /> Pito?Grout Inspection b tit. Date Final Area <br /> by <br /> Additional Comments: _ <br /> Date <br /> ❑ Stk 466.6781L.tr— <br /> Lodi 369-3621 El Manteca -7104 racy 895-6385 <br /> Applicant- Return all 01 environmental ealth Permit/Se '' es 1 1 E. Hazelton Ave. P. Box 2009, Stk., CA 95201 <br /> � ti'r/v 11,1, J5 � <br /> 311 a — <br /> r <br /> FEE h'f u1&,INFO AMOUNT DUE AMOUNT REMITTED � <br /> RECEIVED BY <br /> _ // // ,CASH DATE PERMIT <br /> F EH 13-24(REV.10!831 �� �-.J-� +L1O� <br /> EH 1426 `J •S <br />