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APPLICATION FOR PERMIT <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE TION AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i (Complete in Triplicate) <br /> I�. <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 Courity 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 /> Jab Address � s� City <br /> Lot Size PM <br /> S <br /> Owner's Name "t Address '177's w' Phone <br /> Contractor Addres License No4 4 _Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> »� R ❑ OTHER ❑SYSTEM REPAIR PUMP INSTALLATION� { <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial &VvjWr ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing r <br /> ❑ DomesticlPriva fe ❑ Gravel Pack! ElTracy Type of Casing Specifications <br /> M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ----- <br /> E I Irrigation --.-Approx.1 Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done Type of Puml:i!4 _-__ H.P State Work Done ct } <br /> Well Destruction ❑ Well Diameterr Sealing Material Itop 501 7q)� <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION [ I DESTRUCTION l l INo septic system`permitted if public sewer is <br /> available within 200 feet.l <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:'"I Water table depth j <br /> SEPTIC TANK ❑ Type/Mfg I Capacity 'No. Compartments <br /> PKG�TREATMENT PLT. CI _J1 Method of Disposal _ <br /> jq- Distance to nearest: Well II <br /> Foundation Property Line !T y <br /> LEACHING LINE ❑ No. & Length-df lines, Total length/size„ <br /> a ' <br /> FILTER BED ." "'; , I] ,Distance to nearest: Well Foundation�� Property Line `R• "y ' Q <br /> SEEPAGE PITS I'I Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i t <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 signattire certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> 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." i.1 I <br /> The applicant for a required inspections. Complete drawing on reverse side. Q(} <br /> - <br /> Signed X Dater <br />� - Tiile: <br /> 4 F EPARTMENT USE ONLY <br /> Area <br /> Application Accepted by Da , <br /> ns ction b Date Final inspection by ate <br /> F-0 <br /> Pit or Grout I <br /> Y <br /> l� I� <br /> Additional Comments: C <br /> ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C3 Tracy 835-M5 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> E <br /> FEE AMOUNT DUET AMOUNT REMITTED`, CK 11 CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> 3 s G � �—k9 <br /> s.EH 13-241REV.tIn5t 1— 131�� <br /> £H t4-26 <br />