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a APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) w. <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.-,: i <br /> _ � } <br /> 0 (lG� e City � f`Q� Lot Size ,F,.C�-�- PM <br /> Job Address /p¢ <br /> Owner's Name �Te�'U� Address ` Phone <br /> � l� ! !Q <br /> Phone <br /> Contractor.� /"� �Address c�. � License No. <br /> ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I-] DESTRUCTION ❑ <br /> hEl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public Fl Other ❑ Delta Depth of Grout Seal & Type of Grout d <br /> r <br /> rz <br /> I`I.Irrigation _..Approx.-Depth 4 I Eastern Surface Seal Installed by_L 4 <br /> p 't" r H.P." ._ ` State Work Done <br /> Repair Work Done ❑ Type of Pum •` + <br /> f } <br /> t Well Destruction ❑ Well Diameter Sealing Matefial.(top 501 t3 f <br /> r t'Filler Material'f8elbw 50') r$, + <br /> Depth i <br /> TYPE OF SEPTIC WORK: NEW iNSTALLATFON. FiLPAIRlAD:DITION`l l•:,DESTRUCTION l I (No septic system permitted if public sewer is ; <br /> w - • m '-" -' 's available within 200 feet.) <br /> 'Installation will serve: Residence Commercial Other <br /> Number of bedroom <br /> t Number of living units: �— <br /> Character of soil to a depth of 3 feet: ?tJ Water table depth <br /> $ SEPTIC TANK ❑ Type/Mfg. + Capacity No. Compartments <br /> 1 <br /> PKG. TREATMENT PLT, 0, 1.1 % - Method of Disposal <br /> Distance to nearest: 't Well T!y---- Fou ndatidn-/�— Property Line , F i <br /> _ s <br /> LEACHING LINE � No. & Length of line sp,�,J <br /> �!j Total length/size <br /> FILTER BED ❑ Distance to nearest: .' Wel! rFoundation Property Line�._`.,-`l r <br /> SEEPAGE PITS 11 Depth­"­ Size ' _ Number <br /> t SUMPSLl Dist nce to nearest: Well Foundation w-� Property-Line— —4 f <br /> i DISPOSAL PONDS ❑ f%` •:.; <br /> I hereby certify that I have prepared this application and that the work wiH tie'done.in accoraance`with•,San Joaquin 66i ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> FHome owner or licensed agel signature cenifies,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,ta become'subject to workfnar'1 s compensation laws of California." Contractor's hiring or sub-contracting signature <br /> a certifies the following: "I certify that in the performance of the work for which this permit is issu`M,.I,shall employ_persons subject to workman's compensa- <br /> tion laws of California. <br /> The applicant must call for all quire nspect�ions.. Complete drawing on reverse side. <br /> b Title: Date: <br /> Signed X�- , <br /> r <br /> F EPARTMENT USE ONLY <br /> 4 �; Date Area <br /> Application Accepted by <br /> t Date ~it ' <br /> :Pit or Grout Inspection by Date Final Inspection by — <br /> ' I <br /> Additional Comments: - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 i❑ Manteca '9234164— �❑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 AMOUNT OUE AyMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. r <br /> +.EH 13-24 rREv.1114 51 <br />