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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 1601 E. HAZE'T ON AVE., STOCKTON, CA <br /> r 111 Telephone (209) 466-6781 <br /> Y1 PERMIT EXPIRES TYEAR 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. �t <br /> KJob Address D 3 SD ��l City `Y )eyyi Lot size PM <br /> Owner's Name l ,� � Address 2 F- �(LAC) Phone <br /> Contractor ��� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPL EMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION. ❑ SYS M REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTaC TANK _ SEWE LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICU TU WELL OTHER WELL PITSISUMPS x <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Wel{ Excavation Dia. of Well Casing ` <br /> L7 Domestic/Private 1-1 Gravel Pack ❑ Tracy pe of Casing Specifications <br /> 1-1 Public F1 Other I 1 Delta D 'th o%Grout Seal Type of Grout--- <br /> D <br /> p,, <br /> I I Irrigation -Approx._Depth_Y 1.I Eas rn Su ace Sea`installed by _ W <br /> �. Ty -tom �� .;.--� --- <br /> Repair Work Done ❑ Type of~Pump H.P. State Work Done <br /> Well Destruction ©. Well-D a eter Sealing Materia flop 50') �s <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATI REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is <br /> f available Gvithin 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other t <br /> �. Number of living units: Number of bedrooms &r i;o K 'foo vD'r <br /> Character-of soil to-a-depth of 3 feet: Lo ^ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg VkL Cb-c-IrTA4P­ Capacity—-_�2 'D No..Compagrnents �— <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> -Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines 3Q - Total length/size <br /> FILTER BED-- = ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS ❑ 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, 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 lo wing: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> aws a. <br /> of aft rni <br /> tion l " _ <br /> The appiicantst�callrall req 'red inspections. Complete drawing on reverse side. q <br /> Signed Title: Date: r)- 1 L <br /> ^�jk,.- <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b Cu`� �y Date 1 Acca <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> D Silk 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 /> i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CKS0 RECEIVED BY PATE PERMIT NO. <br /> EH 13-24(REV. i a sf p� <br /> EH 14-28 <br /> r Q r <br />