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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR PERMIT SFE Ike. PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED <br /> Telephone (209) 466-6781 12 1988 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SEP ;3 <br /> .y (Complete in Triplicate) <br /> jyVIRONMENWAf <br /> u��r �li�ation is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work�r� an Joaquin <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules <br /> Local Health District.? <br /> th d (/ City Lot Size PM <br /> hone Job Address ? <br /> Owner's Name �w� _ Address <br /> /�� ►'/ <br /> Contractor <br /> !//�f L 1 �Y Address /a License No. <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ (� <br /> PUMP INSTALLATION � v <br /> DISTANCE TO NEAREST: SEPTIGTANK � SEWER LINES 2 <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TI N Dia. of Well Casing �` S <br /> ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 11, <br /> ' <br /> Type of Casing 4� Specifications <br /> ❑ Domestic/Private Gravel Pack ❑ Tracy e !� Type of Grout <br /> i`1 Public XOther�l104r❑ Delta Depth of Grout Seal At—d � � � <br /> I I Irrigation _,.Approx. Depth I I Eastern 11,10,Z—. <br /> urface Seal Installed by <br /> Repair Work Done ❑ Type of Pump �CL/22 <br /> H P L Z— State Work Done — <br /> ateriallto 60'i <br /> Sealing P <br /> Well Destruction <br /> ❑ Well Diameter , <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION l I DESTRUCTION l 1 (No septic yin system permitted if public sewer is <br /> k <br /> Installation will serve: Residence_` Commercial— Other <br /> I` Number of liviriq,units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> pistance to nearest: Well Foundation Property.Line <br /> + Total length/size <br /> LEACHING LINE 171No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: <br /> Well Foundation Property Line <br /> Number <br /> � <br /> SEEPAGE PITS l 1 Depth Size Numy <br /> " SUMPS Cl Distance to nearest: Wel! Foundation Property Line <br /> i 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 shalt 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 iri the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Califofrl <br /> The applicant mu call f r spections. Complete drawing on ra 'si�d/. <br /> Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY [� <br /> Date_ /��' Area <br /> Application Accepted by t <br /> Pit or Grout Inspection by <br /> l Date Final inspection by Date <br /> See- <br /> El 6M /Or 47 <br /> Additional Comments: , <br /> Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -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 CK' RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED ' <br /> +.EH 13-241REV.1/851 <br /> 0 EH 14-26 <br />