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i <br /> APPLICATION FORPERMIT , <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICTOO )E <br /> r ' 1601 E. HAZELiON-AVE., STOCKTON, CA gJJUh <br /> Telephone 12091 466-6781_ <br /> F " , �. . . ­f r{ mPen :a N:0 :5 ,.4984; <br /> PERMIT EXPIRES 'I,YEAR.FROM DATE ISSUED_..,,, q k .,-I} .,. : <br /> ",,.(Complete in Triplicate) : 'SIS-IN❑❑.�OAfQUIN LOCAL , <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the'wo�li heFAin dr �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 o the San Joaquin <br /> Local Health District. <br /> r/ J p� V'V 61y\ 1'fit r i'.�h'. '; ,''r1': i f?. i . .t I 0-:s <br /> Job Address _ /411 .. ` t�.�Y Lo#Size . . PM <br /> c <br /> S <br /> Owner's Name + Address �� Vj C i✓t`�1 Phane'� <br /> Contractor's Name-' License No. — Phone <br /> 'TYPE OF WELLIPUMP: NEW WELL❑ WELL REPLACEMENT ❑ DESTRUCTION ❑- <br /> PUMP INSTALLATIOON�°�❑ SYSTEM REPAIR%� OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP, LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> gl <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Dept ❑ Eastern Surface Seal Installed by- <br /> Repair Work Done ® Type of Pump iLw H.P. IZI + State Work Done ka <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Ll (No septic system permitted if public sewer is J�1 <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: 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 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Y-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: r : , <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 riot <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 applicantust call for all re aired s tions. Complete drawing on re)erse side. <br /> Signed Title: Ll 1 ttS c Data: <br /> 12 FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: ` <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638.5 <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 REMITTED CK RECEIVED BY' DATE PERMWNO.' <br /> INFO CASH <br /> + EH 13-241REV.101831 <br /> EH 14-26 Lis, A <br />