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`Do <br /> APPLICATION FOR PERMIT - - <br /> SAN'JOAO,UIN'LOCAI: HEALTH DISTRICT <br /> _ � <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 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 Ryles and Regulations of the San Joaquin <br /> Local Health District. r. .� k. '... <br /> Job Address �J v City' I LotYSize { PM <br /> = Owner's Name ddress' r Phone <br /> Contractor E:1� Address E-Q.c 'nG \_LLSd _ _License No. a5Sf`34�3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER I] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA-•CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial C1 Open Bottom ❑ Manteca Dia3,of-Well Excavation Dia. of Well Casin <br /> ❑ Dom�tic/Private C] Gravel Pack ❑ Tracy Type of Casing Spe ifications <br /> F] Public 11 Other El Delta Depth of Grout SealType of Grout 03 <br /> 4 CI Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done L7ype of_Pump_ _ H.P. State Work Dong e <br /> Well Destruction ❑ Well Diameter— Sealinb Material Itop 50') <br /> Depth Filler Material {Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION-❑ �fNo septic system permitted if public sewer is <br /> ,,� $, ✓ 4 ' available within 200 feet.) # <br /> Installation will serve: Residence• Commercial_ Other 2 j�}fj <br /> Number of living units:' � � Number of bedrooms <br /> lr <br /> Character of soil to a depth of 3 feet: .__ .� —�'4Y _Water table depth <br /> Ir.- - Nil- <br /> SEPTIC <br /> TANK %❑ Type/Mfg J.___�_CapaciN-�_ - -�-..No--Comparrtments <br /> "�.PKG. TREATMENT PLT, O '^ "-" Method of Disposal <br /> a <br /> e •.Distance to nearest: Well �` ` �Foundation I Property Line <br /> LEACHING LINE e- No. & Length of lines t Total-IL-ngth/size <br /> FILTER BED Ll Distance to nearest: ;Well Foundation ) Property Line <br /> r SEEPAGE PITS ❑ (Depth �" = Size I Number <br /> SUMPS : Distance.t nearest: (Well Foundation, I Property Line <br /> DISPOSAL PONDS ❑ e. _ i <br /> I hereby certify that I have prepared this application anFd that the work will be'done in'accordance with San Joaquin county ordinances!state laws, ancl� �. <br /> rules and,regulations of the San Joaquin Local Health-District. I I I <br /> Home owner or licensed agent's-sigriature certifies lie following: "I certify that in tWperformance of the work for which this permit is issued, I shall not <br /> employ airy 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 cerlifVthat 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 st call for equired inspections. Complete drawing on reverse side. <br /> A . i <br /> `• Signed Title: Data: - k, <br /> n 4 OR DEPARTMENT USE ONLY f_4 <br /> Application Accepted by rDate Area i t <br /> Pit or Grout Inspection by Date F` Fina sp ction,by- n Dal /,9 <br /> .Additional Comments: <br /> ❑ Stk 486-6781 ❑ Lo 369-3621 ❑ M823-7104 El Tracy"=835-6385 <br /> Applicant- Return all copies to: Environmental Health ermit/Services 1601 E. Hazelton.AVe.,`P.O. Box 2009,.Stk., CA 95201 <br /> } <br /> FEE AMOUNT DUE AMOUNT REMITTED CK +� RECEIVED BY DATE PERMIT"NO. I <br /> INFO { - CASH <br /> + EH 13-24IREV. /a51 5 - <br /> EH 14.26 14 <br /> F <br />