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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1609 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> �1�R rJ ✓ �" PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ®�`4p1S� < ',. .t• (Complete in Triplicate) <br /> I��ionielh�reby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> rRSN.compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1851 for well/pump and the Rules and Regulations of the San Joaquin <br /> Loca) Health District. <br /> Job Address a. A City Lot Size PM <br /> Owner's Name L cif y !/'�(�-� Address l �� 1�0 1 <br /> /It (I JlIAL/ 7(!� �,•�[� _ Phone <br /> Contractor's Name _ License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L] DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ?!r— 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 /> ,2rpomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by n/1 <br /> Repair Work Done ❑ Type of Pump ,..4. st H.P. t State Work Done 1 <br /> U1i i <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 04s <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: .NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> z.} 1 available within 200 feet.) <br /> Installation will serve: Residence f Commercial_ Other ) <br /> Number of living units: Number of bedrooms } <br /> . . y. <br /> Character of soil to a de'�pth of 3 feet: � — Water table depth <br /> SEPTIC TANK ElType/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 Property Line <br /> DISPOSAL PONDS . ❑ I <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, l 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 mpat tail for ired inspections. Complete drawing on r v se si e. <br /> Signed _ Title: -- Date: <br /> L FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date'. J� t�Area <br /> Pit or Grout Inspection by {" Date Final-Inspection by-._ �_%4 r 4^ Date���5 <br /> Additional Comments: _ <br /> ❑ 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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH 13-24(REV.10183) f a <br /> EH 1426 <br />