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.v <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT <br /> 1 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED <br /> Telephone (209) 466-6781 N 0 V 3 D 1 <br /> PERMIT EXPIRES IkYEAR FROM DATE ISSUED 988 <br /> (Complete in` • <br /> Triplicate) ENVIRONMENTAL <br /> r S <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the worp �1 lication is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rqles an e u 4411 he San Joaquin 1 <br /> Local Health District. « <br /> n y A <br /> Job Address I� 34S ` S.'. aA,ty Lot Size PM <br /> Owner's Name i714 Address MJ Phone - <br /> Contractor. J 7l-1 XJLAddress �e2f)0� &3./4I/V License No��©l� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR.❑ 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 /> El Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private LJ Gravel Packx 71Tracy Type of Casing Specifications <br /> LlPublic Ll Other- A0 Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern _.� ZZ <br /> Sea!-.Installed by W ¢• <br /> 'Repair-Work D6rf6 —❑ Type of Pump .6� H.P. Z State Work Done Kfmaye <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 '' -/ ,J?�; <br /> Depth ° ;Filler,Material-{Below 501 y A- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIR/ADDITION ❑ DESTRUCTION j], (No septic system permitted if public sewer is <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 [, 9 <br /> FILTER BED ; ❑ Distance to nearest: Well Foundation Property Line ry <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation - Property Line 4 <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." Contractors 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 mus II for all required i ection Complete drawing on reverse side. <br /> Signed X_ Title: Date: <br /> FOR DEPARTMENT USE ONLY `� <br /> 1 s <br /> i <br /> Application Accepted by `" e, `R f 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 /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> 1� <br /> + EH 13-241REV.I/as) �� -7 f I SNK- <br /> EH 1426 <br />