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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> ( ' Telephone (209) 466-6181 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ap (Complete in Triplicate) <br /> plication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and R <br /> Local Health District. wok herein described. This application is <br /> { Regulations of the San Joaquin <br /> ! Job Address yam., <br /> City C Lot Size 1 yG <br /> l Owner's Name = e�A PM <br /> Address <br /> Contractor_- �, Irl f(-�f� <br /> Phone <br /> TYPE OF WELL/PUMP: f Address 1 k <br /> NEW WELL,❑ License No. Phone 1 <br /> PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ TRUCTION'❑ <br /> ' <br /> DES <br /> SYSTEM REPAIR �❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> �_ SEWER LiNES � DISPOSAL FLD. <br /> FOUNDATION �� AGRICULTURE WELL PROP. LINE <br /> INTENDED USE TYPE OF WELL OTHER WELL—_ PITS/SUMPS <br /> ❑ Industrial PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom <br /> ❑ Domestic/Private ❑ Manteca Dia- of Well Excavation <br /> ❑ Gravel Pack ❑ Tracyr T Dia. of Wel! Casing <br /> l] Public - 17 Other Type of Casing ' <br /> ID Delta Specifications <br /> ❑ Irrigation � Depth of Grout Sea!- . _ y <br /> —Approx. Depth EJEastern Type of Grout <br /> Surface Seal installed by <br /> Repair Work Done <br /> ❑ Type of Pump H P <br /> Well Destruction ❑ Well Diameter State Work Done <br /> Sealing Material (top 50') <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW}NSTALLATiON ❑ REPAIFR/ADDITION lter Material Below 50'} - <br /> ii y DESTRUCTION ❑ f No septic system permitted if public sewer is <br /> —installation of will serve: Residence� Commercial available within 200 feet.) <br /> Other� � <br /> -b Number of living units: ---F— Number of bedrooms 3 <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> !K G. TREATMENT PLT. ❑ "- -- Capacity No. Compartments <br /> %.� +_ S' Method of Disposal <br /> Distance to nearest: Weil <br /> Foundation_ Property p rty Line�- <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Tota! length/size <br /> Well 'Foundation <br /> ,. � Property Line� <br /> SEEPAGE PITS Depth r <br /> SUMPS Size e`. <br /> IJDistance to nearest: Number I <br /> DISPOSAL PONDS ❑ Well�+Foundation <br /> Property Line <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, sate 1 <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: aws, and <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting s' nature <br /> certify that in the Performance of the work for which this permit is issued, I shall not <br /> certifies the following: '•I certify that in the performance of the work for which this <br /> tion laws of California." permit is issued, I shall em la <br /> The applicant must call far all required ins p Y Persons subject to workman's compensa- <br /> tion <br /> inspections, Complete drawing on reverse side. <br /> Signed <br /> Title: <br /> Date: <br /> Application Accepted by <br /> 45�� <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Pit or Grout Inspection by Date `Gr Area <br /> Date "'- <br /> �� Final Inspection by ` <br /> Additional Comments: Date ✓ y � <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 AMOUNT DUE r <br /> INFO AMOUNT REMITTED CK <br /> CASH RECEIVED By DATE <br /> f EH'13-2/(REV.�ias� PERMIT`N0. <br /> EH 14-28 <br /> �o �7 SQ <br />