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- APPLICATION FOR PERMIT I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA IV I <br /> Telephone (209) 466-6781 RECD <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � <br /> (Complete in Triplicate) 'of <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hr ' pprAfion is ' <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the RRn <br /> vI�L � gan Joaquin <br /> Local Health District. p� <br /> AA f <br /> Job Address (03 � �•+ L�7/ 1Jvt -- City Lot Size G-.tzy-f T - PM <br /> Owner's Name­D utdg:&& wAe � Address - <br /> 1 Phone 406 !:41P <br /> Contractor t� t Address'-i7-5 E. M, SlWS License No,5���� Phan <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER! i 6u-% ,O Ly�1C$� <br /> DISTANCE TO NEAREST: SEPTIC TANK _t4 A SEWER LINES WA_ _ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION �__ AGRICULTURE WELL; F OTHER WELL �!+� PITS/SUMPS %A <br /> - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation (a- rt Dia. of Well Casing <br /> I <br /> ❑ Domestic/Private ❑ Gravel Pack IK Tracy Type of Casing lwxe Specifications <br /> FI Public Wgjn. "' Other F1 Delta Depth of Grout Seal XLrType f Grout . <br /> I I Irrigation� � L�_Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') {�} <br /> Depth Filler Material (Below 501 C <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 3 DESTRUCTION I 1 INo septic system permitted it public sewer is LA <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 I Depth Size Number <br /> SUMPS 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, 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 /> I'I 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 st caH for all <br /> requireo inspections. Complete drawing on reverse sidle.. / <br /> Signed X C` Title: Z_Z L a/0' Date: <br /> T i <br /> F. EPA TM 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 835-6385 <br /> II 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 t A R RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +.EH13-24IREV.J/K5l �� o4L40s 40h.. v <br /> EH 14-28 �� 11 <br />