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APPLICATION FOR PERMIT ! U V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209)•466-6781 <br /> PERMIT EXPIRES I'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 /> PM <br /> Joh Allddress `fSf'/ City Lot Size <br /> !_"/tl ,e 7 //��© 6a GPJc'ffrC�LC(dSP <br /> Owner's Name Address A Phone <br /> IPS <br /> Contractor Address x License <br /> _ TYPE OF WELL/PUMP: NEW WELL. ,,_,SWELL REPLACEMENT DESTRUCTION Q <br /> _ ;= M <br /> PUMP,INSTALLATION 1 SYSTEM REPAIR L1 \_ <br /> c <br /> DISTANCE TO NEAREST: SEPTIC TANK /.S"�" ' _ SEWER LINES ,� DISPOSAL FLD. PROP. LINE _,r—&O <br /> FOUNDATION AGRICULTURE WELL OTHER WELL* PITS/SUMPS <br /> 4 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom LI Manteca Dia. of Well Excavation s1 Dia. of Well Casing <br /> Domestic I Private Gravel Pack ❑ Tracy Type of Casing - Specifications./,eO., <br /> 'i Public ❑ Other F1 Delta Depth of Grout Seal s?F Type of Grout_ <br /> I I Irrigation Approx. Depth i I Eastern Surf ce 5eal Installed by - <br /> Rep iir Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction Well Diameter Sealing Material (top 50') <br /> Depth-L Material (Below,501 #I_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION L l "„DESTRUC. ION l'l,"INo septic.system permitted if public sewer is <br /> available within 200 feet.] -� <br /> ns <br /> Itallation will serve: Residence— 'Commercial— Other------! <br /> n <br />[ Number of living units: Number of bedrooms <br /> k Character of soil to a depth of 3 feet: Water table depth <br /> -SEPTIC TANK D Type/Mfg Capacity No. Compartments <br /> a t <br /> i PKG. TREATMENT PLT. El .� ,�•,��. -; ,. -��..s.� ;� Method of Disposal <br /> I`Fk Distance to nearest: Well -�` Foundation Property Line <br /> I Je <br /> t LEACHING LINE ❑ No. & Length of lines Total length/size <br /> I FILTER BED ❑ Distance to nearest: Well Foundation Property Line i <br /> SEEPAGE PITS I I DepthSize _ Number <br /> q ,,.".�•_._--,_;.._ - ---.,�r- - �.-sem. . --- --•....,--^�---.,,�.,.-- •-- t y. <br /> UMPS- �� Ll 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 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 /> t 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 tR"e 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 applicarit must call for-all re fired inspections,gumplete drawing on reverse side.`AL <br /> Title: r:i - Date: . <br /> Signed X �-.- <br /> FOR DEPARTMENT USE ONLY + <br /> Application Accepted by Date - Area <br /> Pit or Grout Inspection by Date Final Inspection by Date S <br /> Additional C meets: All 1/ 6edLJ tea i <br /> EIStk 466-6781 j' o I anteca 71 Tr cy 8151385 <br /> Applicant - Return all copies.to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE f <br /> I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> S C <br /> ♦ EH 13-24(REV.t i e 5) <br /> EH 14-26771 <br />