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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health"DistTict for a permit to construct and/or install the work herein described.This application is <br /> llunty Ordinance No. 549 for sewage or No. 1862 for wepump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin Co <br /> Local Health District. <br /> �/.^^ ity r;+1[e�l Size � ,�.— PM" <br /> Job Address <br /> Owner's Name <br /> kjp s7"e-i'eul Address ' Phone <br /> bY <br /> Contractor Address License No. � hone <br /> f TYPE OF WELLIPUMP: NEW WELL 111~ WELL REPLACEMENT 171 _ DESTRUCTION ❑ T �w <br /> _ # <br /> PUMP._INSTAL-LATION.I�" ----�-�-SYSTEM REPAIR ❑ OTHER ❑ <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ; <br /> FX <br /> FOUNDATION AGRICULTU9E WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE" .� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. i f WeII Casing <br /> ❑ Industrial f <br /> Specifications <br /> C� ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Type of Grout <br /> M Public M Other ❑ Delta a Depth of Grout Seal <br /> h,.. r � <br /> I I Irrigation � —Approx..0epth�-l_L Eastern Surface Seal..lnstalled•by---- -—� "iCl- <br /> € State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. <br />` <br /> Well Destruction ElWell Diameter Sealing Material (top 501 I <br /> Depth Filler Material (Below 501 f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITIO + DESTRUCTION l I 'I No septic system permitted if public sewer is' <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial 'Other <br /> Number of living units: __/_ Number ofbedrooms <br /> 0 R� , i f � <br /> F <br /> Character of soil to a depth of 3 feet: _� t r Water table depth <br /> � <br /> k <br /> SEPTIC TANK L3 Type/Mfg Capacity No. Compartments <br /> 1 t <br /> Method of Disposal <br /> PKG. TREATMENT PLT. L1M <br /> Distance to nearest: WeII )Foundation Property Line <br /> F,. <br /> LEACHING LINE No. Jit Length of lines 4 ' Total length/size <br /> a ` <br /> t FILTER BED El Distance to nearest: Well Foundation Property } <br /> a <br /> SEEPAGE PITS bd. Depth <br /> Size Number <br /> SUMPS !❑ Distance to nearest: Well Foundation ! Property Line <br /> I DISPOSAL PONDS I❑ - - y <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 /> I 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 /> certifies the flowing: "I dertify that in the performance of the work for which,this permit is issued,1 shall employ persons subject to workman's compensa <br /> tion laws o alifornia." ` <br /> The applic n must call-for all req 'ed ' s etions.'Gomplete drawing on reverse side. <br /> 1- <br /> Signe Title: _ ��"r'�E'r'_-'f Date: <br /> _ OR DEPARTMENT USE ONLY <br /> Date_ Area . <br /> A 'cation Accepted byi <br /> j Data Final Inspection by �/ ^'( "� Date` � P,44 <br /> I Pit Grout inspection by jS <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Mante 823-7104 ❑ Tracy 835-6385 n <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 CASH <br /> H13-241REV.��H5f f��I 7-WYQ,3 <br /> '14-26 v <br />