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Y/ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA . G3.. <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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 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. # <br /> lI Job Address 170 ) City Lot Size O� PetM6, A <br /> - <br /> Owner's Name ' 1 � � l <br /> VIE �/N1_.._4��� Address �� Phon �pI 'AMP <br /> Contractor . Address License No.& Phone �Z <br /> TYPE OF WELL/PUMP: ;NEW WELL ❑ g� WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION *f;JAffWe>JV jJ-SYSTEM REPAIR L OTHER ❑ <br /> 1 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 PROBLEMAREKi ;;CONSTRUCTION SPECIFICATIONS <br /> ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private LJ Gravel Pack ❑`Tracy ,Type of Casing Specifications } <br /> f"1 Public ❑ Other F1Delta Depth ofGroutSeal Type of Grout _ /r;] <br /> I f Irrigation _. kpprox. Depth l f Eastern Surface Seal Install by _ l.i <br /> - Repair Work.Done (Typef Pump IN"khu.0 H.P. _-1,00 State Work Done_ G <br /> Well Destruction ❑ Well fiameter Sealing Material {top 50') <br /> f <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I,i DESTRUCTION I I INo septic system permitted if public sewer is <br /> I <br /> y available within 200 feet.) <br /> ° Installation will sere: Residence- Commercial Other <br /> j <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3feet. f Water table depth <br /> SEPTIC TANK ❑ Type/I'fg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ # Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ NJ &'Cength of lines Total length/size <br /> FILTER BEd ❑ DiMance to nearest: Well - _Foundation Property Line.- <br /> 4.7 <br /> ine4.i' <br /> SEEPAGE PITS I 1 Depth Sizel — — ` Number <br /> -h.f <br /> SUMPS } ¢r, L7 g Distance to nearest: Well,:r`" " T Foundation Property Line <br /> DISPOSAL PONDS {,.[I1 r- Ll <br /> l I hereby certify that I have repared this application and that the work will b4-none in accordance with San Joaquin county ordinances, state laws, and <br /> f rules and regulations of the San Joaquin Local Health District.,. 1 l f <br /> Home owner or licensed agent's signature certifies the following.,-1 certify that in the performance of the work for which this permit is issued, I shall not <br /> f employ any person in such mannk 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,wo'rk.fdr which this permit is issu ld, 1 shall employ persons subject to workman's compensa- <br /> tion laws of.California." - <br /> The applicant„ f all r spections. Complete drawing on,rev rse e. <br /> �a <br /> y Signed X m Title-- Date: rr <br /> I FO DEPARTMENT USE°DNLY <br /> Application Accepted by Date rea <br /> b 7 <br /> I <br /> Pit or Grout Inspection by 1 Date 4Inal Inspectionttby DateZ � <br /> Additional Comments: <br /> ❑ Stk 466-6781 1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Sax 2009, Stk„ CA_95201 <br /> FEE i UK 4 <br /> INFO AMOUNT DUE AMOUNT REMITTED 'CASH RECEIVED BY! DATE PERMITNO. , <br /> f <br /> +.EH 1 <br /> 3-24IREV.1/n51 /"n� � <br /> {A EH 14-28 (��f <br />