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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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`he work herein described. This application is ; <br /> made in compliance with San Joaquin County Ordinance No.50.9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> .tom' <br /> 32 Lot Size PM <br /> Job Address <br /> JLf City � � <br /> Owner's Name 4 Address 3�� +✓ �"-�1L L f:� � I Phone <br /> Contract Addrl� 4 ' !cense No.� Phone-j y <br /> TYPE OF WELL/PUMP: �° NEW WELL d WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK,. SEWER LINES DISPOSAL FLD. PROP: LINE_ <br /> - — ^- FOUNDATION " -" AGRICULTURE WELL - " -OTHER WELL PITSISUMPS <br /> I LADED USE TYPE OF WELL 'i PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom -❑"Manteca ; Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Cl Gravel Pack ❑ Trac . Type of Casing Specifications <br /> FI Public f! Other Cl Delta'--r Depth of Grout Seal Type of Grout <br /> A rox. Depth 1^I,Eastern Surface Seal Installed by ! <br /> 13 Irrigation --"- PP �`. <br /> fid(1t. l' l' <br /> Repair Work Done ❑ Type of Pump,��.•r•c,Q�-' H•P.�� . State Work Done <br /> Well Destruction ❑ Well Diameter '-Sealing Material Itop 501 <br /> Depth Filler Materiai (Below'51i1 -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f I DESTRUCTION I I (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 R <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg - T Capacity No. Compartments a <br /> PKG. TREATMENT_PLT. ❑ Method of Disposal <br />` Distance to neaiest: ,,'Well� Foundation Property Line <br /> LEA H NG LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> l SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS L l 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, andT <br />` rules and regulations of the San Joaquin Local Health Di§ttict. <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 must c 11 or all required.insspections, Complete drawing on rever a side. <br /> Title: Date: <br /> t Signed X - <br /> OR DEPARTMENT USE ONLY- � <br /> Date <br /> w <br /> I � � A.Area' <br /> Application Accepted by <br /> E <br /> a <br /> Pit or Grout Inspection by Date Final Inspection by DateY S �(C7 <br /> Additional Comments: <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 f <br /> i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEENFO AMOUNT DUE AMOUNT REMITTED 0 �CASH RECEIVED BY DATE PERMIT NO. <br /> r.EH 13-24(REV.1 i n 5) r� �{ p Q <br /> "" EH 14-26 —•Z� <br />