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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 TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) j <br /> i <br /> s <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 f <br /> 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 Joaquin <br /> Local Health District. <br /> Job Address a z-Z� \ 'f 1 I, City t Q� Lot Size PM F <br /> 5 <br /> Owner's Name _�C>S t�1�N C'S Address �`Z-3 r Q Phone vy <br /> Contractor Address '•" 0e0S License No. Phone yl6ti-Ii0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ " <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 CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> E i'l Public (7 Other n Delta Depth of Grout Seal Type of Grout--­ <br /> I <br /> I I Irrigation _--Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter_ Sealing Material (top 50') <br /> Depth Filler Material (Below 501 1 <br /> TYPE OF SEPTIC WORK:; NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTIO 1 1No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence–r—C6mmercial_ Other <br /> Number <br /> ^ of living units: n Number of bedr6omv-- <br /> 7�. <br /> Character of soil to a depth of 3'feet: Water table depth r <br /> SEPTIC TANK ❑ Type/Mfg " Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ \ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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. <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." J <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Xl t- _ . W WV�ip�.,IAA 15gaJ 1_ Title: 6 L- e r S 0 Date: CSS Z:1 <br /> +�. FOR DEPARTMENT USE ONLY <br /> Application Accepted b _ date Area �✓ �! <br /> Pit or Grout Inspection by Date- Final Inspection by Date <br /> Additional Comments: - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> . EH 13-24(REV.iiws) �� � S7� � IF&7-2=009-71 <br /> EH 1�-2e <br />