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S <br />P2 1-1984 <br />SAN JOAQ U i N LOCAL <br />HFAt..TH ©ISTMOT <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZEL T ON 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 />lob Address &--a/ City/lam Lot Size PM <br />Owner's Name &4�` -mss Address /16 <br />P�U_ &�4,&one ^!J .Q <br />� <br />4000tP 23 9' <br />Contractor's Name �� License No. <br />L-Q'tF' Phone <br />TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP INSTALLATION ❑ <br />SYSTEM REPAIR ,0' OTHER La - <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 <br />CONSTRUCTION SPECIFICATIONS <br />❑ Industrial ❑ Open Bottom ❑ Manteca <br />Dia. of Well Excavation Dia. of Well Casing <br />domestic/Private ❑ Gravel Pack ❑ Tracy <br />Type of Casing Specifications <br />❑ Public ❑ Other ❑ Delta <br />Depth of Grout Seal Type of Grout <br />❑ Irrigation ---Approx. Deth Eastern <br />Surface Seal Installed by <br />�❑ <br />Repair Work Done ❑ Type of Pump H. P. i <br />State Woy Done <br />Well Destruction ❑ Well Diameter Sealing Material (top 501 <br />Depth Filler Material (Below 501 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: Residence _ Commercial _ Other <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: <br />Water table depth <br />SEPTIC TANK ElType/Mfg <br />CapacityNo. Compartments <br />PKG. TREATMENT PLT. ❑ <br />Method of Disposal <br />Distance to nearest: Well <br />Foundation Property Line <br />LEACHING LINE ❑ No. & Length of lines <br />Total length/size <br />FILTER BED ❑ Distance to nearest: Well <br />Foundation Property Line <br />SEEPAGE PITS ❑ Depth Size <br />Number <br />SUMPS ❑ Distance to nearest: Well <br />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." <br />The applicant mu call fora cared inspections. Complete drawing on rsee(side. <br />Signed _ Title: �! ">�"""�"" Date: G <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by Date Zt Area /_ <br />Pit or Grout Inspection by Date Final Inspection b Date Gy 2 <br />Additional Comments: <br />11 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 />+ EH 13-241REV. 10/83! <br />EH W28 <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />lemRECEIVED <br />CASK I <br />BY <br />DATE <br />PERMIT" NO. <br />S . <br />3 31, <br />q <br />T <br />1 <br />Ir <br />N <br />