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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 City Lot Size PM <br /> Owner's Name s Address Phone <br /> Contractor u" f�1 Address 4`960 l _I License No. Phone <br /> --.»» TYPE OF:.,WELL/RUMP:rW_.„_ NEW WELL_❑._,_... .. V1/ELL,REPLACEMENT•❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑" SYSTEM REPAIR ❑ OTHER El <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD., PROP. LINE <br /> Z FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED-0,SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , <br /> ❑;Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Eiavation Dia. of Well Casing <br /> ❑ Domestic/Prjivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> } Pi�bhcl n Other 171 Delta Depth of Grout'Seal Type of Grout <br /> �u _.. <br /> I I Irrigation _--Approx. Depth' I I Eastern Surface Seal Installed by _ <br /> Repair`'Work Done ❑ Type of Pump H.P. State Work Done.- <br /> Weil Destruction ❑ Well ?iameter Sealing Material (top 50')' <br /> `` Depth Filler Material (Below 501 <br /> I I (No septic system permitted if public sewer is <br /> TYPE`OT'SEPTIC'V1/ORK NEW INSTALL TION 'RE available within 200 feet.) <br /> r; 4 <br /> /ADDITION I N DESTRUCTION <br /> Installation will serve Residence_ Commercial_ Other <br /> _# <br /> iM O <br /> Number,of,living uhrts:' " Number of,„be'droo s 13 <br /> Character of soil to a depth of 3 feet. ” ' Water table depth <br /> SEPTIC TANK Vjype%Mfg Capacity 4d No Compartments <br /> PKG. TREATMENT PLT. ❑ i f Method of Disposal <br /> "Distance't'o'tiearest:"21' Well 0 Fouridtion' "' �a7 °w` ?Property LineO P <br /> lio <br /> FILTERLEACHING BED INE Ell <br /> No. & Length of lines �® Total length/size <br /> Distance to nearest: Well� _° Fouratlation _€Property Line <br /> s t <br /> SEEPAGE PITS IV""Depth Size !/ — Number <br /> SUMPS U� DisYance to nearest.° Well' �" ""Foundat'on' � ' Property tine <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, slate laws, and <br /> rules and regulations of the San Joaquin Local Health Di§trict. <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 Califor'nia."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 must call for aU re uired inspections. Complete drawing on reverse side. / ¢s <br /> Signed X . A Title. J Date: r (J 1 <br /> i <br /> t <br /> FOR OEPARTIIAENT USE ONLY <br /> Application Accepted by Date - r`Ar a <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: `F <br /> ❑ StK 466-6781 EllLddi 369-362'`(: ❑ Manteca 823-7109 O Tracy 835-6385 <br /> FF. Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEECK <br /> INFO AMOUNT DUE AMOUNTREMITTED CASH RECEIVED BY D TE PERMIT'NO. <br /> a.EH13-241REV.t/H51 frI tf J »' F <br /> EH 14-26 <br />