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k� APPLICATION FOR PERMIT <br /> E SAN JOAQUIN LOCAL HEALTH DISTRICT <br />' 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 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 /> Job Address %k Lot Size Y3 PM <br /> Owner's NameE,/1 Address A01V Z41 V /`-� '�' hone 9�/l <br /> Contractor's Name License No. <br /> 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 A / <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !� 17 <br /> ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r <br /> ,*Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing AA Specifications <br /> ❑ Public ❑^ Other p Delta Depth of Grout Seal '— Type of Grout <br /> El Irrigation tO_7!�_Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pumps y H.P. State Work Done <br /> Well Destruction <br /> � - <br /> e , —Sealing tbp50) <br /> � t .yrv. De Depth \Fller -- - <br /> y <br /> Material(Bel.50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> _ ,available within 200 feet.) <br /> Installation will serve:--Residence'" f <br /> Commercial_ Other m-- <br /> �4 <br /> Number of living units: Number of bedrooms ` - l <br /> Character of soil to a depth of 3 feet: . <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg- -- Capacity—1 i No. Compartments - <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> Distance to nearest: Well Foundation + Property Line <br /> LEACHING LINE ❑ No. & Len th of lines` <br /> g Total length/size <br /> FILTER BED ❑ Distance to'nearest: � Well Foundation' j !':L_ Property Line <br /> SEEPAGE PITS ❑ Depth ; f Size. ' Number <br /> SUMPS ❑" Distance to jnearest:j Well Foundation eq 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. +gf <br /> Home owner or licensed agent's signature certifies the_'f6_1116 "I ceiti <br /> g: fy 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 61ifornia."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 <br /> tion laws of California." issueii, I shall employ persons subject to workman's compensa <br /> The applican must call for all re d inspectifflns. complefe drawing on reverse side. <br /> r ` <br /> Signed <br /> Title: F r / <br /> € � � Date: <br /> i FOR DEPARTMENT USE ONLY <br /> Application Accepted by, .• Date r/ ` rY— Area <br /> Pit or Grout Inspection by 1 Date Final Inspection Date _ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ 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 /> FEE INFO MOUNT AMOUNT REMITTED C SH RECEIVED BY DAT/E7 PERMIT';ND. <br /> +EH 13 /� <br /> 24{REV.1e1631 /`� j� <br /> EH 1426 <br />