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APPLICATION FOR PERMIT <br /> 4A _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE ION AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ® � <br /> PERMIT EXPIRES 1 YEAR FROM DATE'ISSUE - APR 3 <br /> (Complete-in Triplicate) <br /> a kation is <br /> ��iw Joaquin L <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install erejn, n <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for+well/pump and. PERMIT/SERVICES <br /> Local Health District. <br /> 19 /G i l^fL Lot Size PM <br /> Job Address <br /> O.Z 4 1^s City <br /> z7z Phone <br /> Address <br /> Owner's Name = <br /> Contractor Address <br /> cis License No. Phone { <br /> TYPE OF WELL/PUMP: NEW WELL_ WELL REPLACEMENT ❑ DESTRUCTION 1.O <br /> PUMP INSTALLATION ❑A ` <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES r— DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK —Gs — <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> Y ­ ° TYPES OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Dia. of Well Casing (� <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial Specifications , <br /> �y Gravel Pack �Tracy Type of Casing <br /> Domestic/Private / R Type of Gro <br /> ❑ Other El Delta Depth of Grout Seal f <br /> ❑ Public Surface Seal Installed by <br /> ❑ Irrigation _�pprax. Depth C1 Eastern <br /> H P State Work Done <br /> Repair Work Dane C1Type of Pump <br /> Sealing Material (top 501 <br /> E Well Destruction ❑ Well Diameter Filler Material (Below 50'1 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION d aNailabpelwithne200 feet.) <br /> rf public sewer is <br /> Installation will se . Residence— Commercial_ other <br /> Number of living units: umber of bedrooms Water table depth <br /> Character of soil to a depth A 3 feet: <br /> Capacity— No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG, TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest: Well <br /> Total iengt " e <br /> LEACHING LINE LlNo. & Length of lines rest: Well Foundation Property Li <br /> ❑ Distance to nearest:l FILTER SED . <br /> ISize Number <br /> f SEEPAGE PITS ❑ Depth <br /> Foundation Property Line <br /> SUMPS L] Distance to nearest: Well <br /> . �,w-DISPOSAl- PONDS _ ❑ <br /> I hereby certify that 1 have prepared this application and that the wok will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home o owner le insuch manner as to becomfies the e sI shall not <br /> ubjectllowing: 111 to workman's compensation lrfify that in the aewsormance of the work for of California."Contractor's which <br /> or sub-cont acissued, <br /> ng signature <br /> employ y person <br /> I certifies the following:"I certify that in the performae of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> nc <br /> tion laws of California." <br /> y The applicant st call for all reg4ire inspections. Comple a drawing on r arse side. <br /> ' itle: Date: <br /> Signed <br /> F DEPARTMENT USE ONLY <br /> Date ``" :n Area <br /> Application Accepted by <br /> Date <br /> Pit or Grout Inspection b Date <br /> 'r< J Final Inspection by <br /> Additional Comm n Tracy 835-6385 <br /> F] Stk 4W6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 <br /> Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ti <br /> FEEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> INFO AMOUNT DUE <br /> y +EH13.241RE1-1/05) L <br /> f EH 14-26 „ ,. <br />