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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 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 Ryles and Reg <br /> Local Health District. ulations of the San.Jaaquin <br /> ' L ,., ... <br /> Job Address - � City Lot Size PM <br /> Owner's NameAddress — Phone <br /> J T 1_14" v a <br /> Contractor. Addres cense No. Phone 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR [ OTHER El <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 CONS7FiUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> t,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done Type of PumR„ dH.P. State Work Done <br /> Well Destruction 11Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below1501 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 71 "DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feel! <br /> Installation will serve: Residence��.. Commercial__ Other rk' <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. ❑ _ tY Method of Disposal <br /> Distance to nearest:..---.-well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines -R'_ t �3 Total length/size <br /> �: <br /> FILTER BED ❑ Distance to nearest �'Well Foundd'tion Property Line <br /> SEEPAGE PITS ❑ Depth Size = Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 4 <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 /> rules and regulations of the San Joaquin Local Health District. 4 <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 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 ust ca11 r all required inspections. Complete drawing on �arse si e. <br /> Signed Title: Date: _ <br /> b <br /> FO D PARTMENT USE ONLY T <br /> Application Accept A r- ,i_ <br /> pp b P y Date `7-'! Area' <br /> Pit or Grout Inspe y Date Final Inspection by bate <br /> Additional Comments: }�. , —; <br /> ❑ Stk 466-6781 17 Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ti 'm <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED 0 RECEIVED BY y. DATE a PERMIT"NO. <br /> + AStr <br /> EH 13-241REV. /B5) -y � ��w ;l <br /> EH 14-26 � ��' 7 C <br />