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APPLICATION FOR PERMIT r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 09 <br /> Telephone (2 09) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> Applicaty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin Coun <br /> Local Health DistricC;9 <br /> 0 6 /4C00.-,4,e <br /> ,. ^.-, + e `57 <br /> y <br /> PM <br /> City Lot Size <br /> Job Address <br /> Address Phone <br /> ? � <br /> 6Owner's Name re �1 <br /> ' ,vtr *9S /aI",rUt� Phone <br /> Contractor Address License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONOTHER ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Q a <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications <br /> El Domestic/ of Casin Domestic/Private ❑ Gravel Pack ❑ Tracy g Type of Grout <br /> M Public n Other n Delta Depth of Grout Seal <br /> 11 Irrigation --Approx. Depth l I Eastern Surface Seal Installed by - 1 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 _ <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I I (No septic <br /> lable cystithin 200 rmitted,if public sewer is <br /> avaInstallation will serve: Residence_ Commercial_ Other <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.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ' <br /> LEACHING LINE ❑ No. &Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll 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 Califo a." <br /> The applicant m II forr u�et�1�G�tions. Complete drawing ona side. <br /> Signed " Title: �...,s�,,,.Jr0,.'-.A Date: <br /> .. � gTM.fNT USE ONLY C y <br /> S"L~�...� � Area <br /> Application Accepted by Date <br /> ,/j`°'\/ <br /> Pit or Grout Inspection by Date Final Inspection by Date— <br /> W , <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 /> E T REMITTED CK RECEIVES BY DATE <br /> FE AMOUNT DUE AMOUN CASH <br /> INFO - <br /> •.Eli 11-?3,}1x1' <br /> Et, <br />