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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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 2e% ® ,,, r f� <br /> {[ City Q-1 Lot Size PM <br /> � <br /> Owner's Name J _ /��y�n „ / LA <br /> Address �LYn I <br /> Contractor Phone <br /> Address �6 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ License No. Phone <br /> PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR OTHER ❑ <br /> -----__ SEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> INTENDED USE TYPE OF WELL OTHER WELL____ PITS/SUMPS _ <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial L1 Open Bottom �------ <br /> ❑ Manteca Dia. of Well Excavation <br /> ,�omestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> 1'1 Public ❑ Tracy Type of Casing <br /> ❑ Other n Delta Specifications <br /> I I Irrigation Depth of Grout Seal <br /> -..Approx. Depth I I Eastern Type of Grout <br /> Repair Work Done p Surface Seal Installed by - <br /> TYpe of Pump H.P. 4Well Destruction ❑ Well Diameter �,t �" State Work Done <br /> De th / 7 Sealing Material (top 50') <br /> TYPE <br /> Depth—, Filler Material (Below 50') <br /> — SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ( 1 DESTRUCTION f I INo septic system <br /> Commercial___- Other 00 feet.) <br /> Installation will serve: Residence available within 2ewer is <br /> permitted if public s <br /> Number of living units: <br /> Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Waltertll�'Qep h� " <br /> PKG. TREATMENT PLT. ❑ Capacity--. No;,:Compartments <br /> Distance to nearest: WellMethod if Pisq8s <br /> Foundation Property Line v U L <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ElDistanceDistance to nearest: Total length/size <br /> Foundation 1 <br /> -- ---_ Property Lind T SERVICF­ 9 <br /> SEEPAGE PITS 11 Depth <br /> SUMPS Size <br /> L7 Distance to nearest: Well — Number <br /> DISPOSAL PONDS ❑ Foundation Property Line <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances s <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: tate laws, and <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contractin <br /> "I certify that in the performance of the work for which this permit is issued, I shall not <br /> certifies the follow' :"I certify that in the performance of the work for which this permit is issued,I shall employ <br /> tion laws of Calif rni .' p g signature <br /> The applican mu all for all require i spections. mplete drawing on r ers p y persons subject to workman's compensa- <br /> Signed X e• <br /> Title: I t` j r y <br /> Date: <br /> % <br /> Application Accepted by FO PARTMENT USE ONLY I <br /> D � 21,1 <br /> Pit or Grout Inspection by ate N <br /> Area <br /> Date_-_ ________ Final Inspection by , <br /> Additional Comments: ry- Date <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 <br /> ❑ 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 <br /> INFO NT REMITTED CK jv\ <br />+.EH 13.26(REV.t i x 5) 3 S,co C-14 CASH RECEIVED BY DATE PERMIT NO. <br /> EH 1d•28 <br />