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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephohe {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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address a�/ City _ j4?,oC&Lot Size PM } <br /> Owner's Name <br /> C.!! ,� + Address Phone <br /> 44'17EF- <br /> I <br /> Contractor Address / tLicense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ _ WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DAPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTiHER WELL PITS/SUMPS <br /> I I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 <br /> S lndustriai—R-Open-Bottom ©-Manteca.------Dia:-o4 Well_Excavationj Dia. of Well Casing <br /> +�} Specifications <br /> 'iomestic/Private ❑ Gravel .acR- �_�Trace Type of Casing � p <br /> fi+?;� <br /> f"] Public -` �� (=1 Other ❑ Delta Depth of Grout Seal � , Type of Grout <br /> I i-Irrigatior^r---;T yx,-Depth,- 1._I_Eastern._�r.S.0. ce_Seal_Instail_ed-by <br /> �� State Work Oor e -/ AQ <br /> Repair Work(Dorfe ❑ Type of Pump H•P I <br /> i' Well{}estructidnfi�-E]—Wefl-Diibmeter Sealing Material (top 50'1 _!i� i -_ <br /> �T <br /> t Depth( Filler Material (Below 501 <br /> TYPE OF 5EPTICEWORK: NEW.INSTALLATION I1 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is <br /> �1- available within 200 feet:} <br /> Installation will serve: Residence— Commercial_ Other ! I <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth_ r{ <br /> SEPTIC TANK ❑ Type/Mfg Capacity I !p No€Compartments y1 V( <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation i 4 <br /> erty line <br /> LEACHING LINE ❑ No. & Length of lines Total length/sizefl <br /> FILTER BED ❑ Distance to nearest: Well Foundation PPr*perry ILine <br /> tj <br /> SEEPAGE PITS 11 Depth Size Numbe <br /> SUMPS 'Ll Distance to nearest: Well Foundationt 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 an Jpaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. I i1 <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 Calif ornig—Contrartor'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." I <br /> 4 <br /> The appliWufk,, allrequir ns. Complete drawing on rev rse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE NLY <br /> Application Accepted by _- Date f Area <br /> Pit or Grout Inspection by Date Final Inspection by Dater' Y'g k <br /> Additional Comments: <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 17 Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.�P.O. Box 2004, Stk., CA 95201 <br /> 1 � <br /> FEE AMOUNT DUE AMOUNT REMITTER CASHRECEIVED BYDATE PERMIT NO. <br /> INFO <br /> +.EH 13-24{REV.I/HE -•� 1-� g'�g �����y <br /> EH 14-2a <br />