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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) <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. f <br /> Job Address { ; Cit <br /> Y Lot Size PM <br /> Owner's Named• /T Address Phone <br /> Contractor,,/V"fherr (1Gr c2� Address AgX, 'E/ License No.r;79 .66 Phan ! S,1o2D <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 V 4 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V <br /> ❑ Industrial ❑ Open Bottom�[D-Manteca-v- :;­Dia--of,Well-Excavation 4.Dia.-of..Well_Casing <br /> ❑ Domestic/Private ❑ Gravel Pack <br /> ID Tracy Type of Casing Specifications <br /> Fl Public 0 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ! I Irrigation Approx. Depth l I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material flop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1' REPAIR/ADDITION l I DESTRUCTIO 1No septic system permitted if public sewer is- available within 200 feet.) n j <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: Water table depth il <br /> SEPTIC TANK ❑ Type/Mfg Capacity° +-� No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size j <br /> FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line <br /> SEEPAGE PITS C I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line H <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wilt 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 ag nt's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not'% <br /> employ any rs i uch nner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the Ito n : "l c i that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- <br /> tion laws of alit n <br /> The applic it required inspections. Complete drawing on reverse side. <br /> Signed X Title: _42i1/f'I� Date: <br /> FOR DEPARTMENT USE ONLY �L I <br /> Application Accepted by Date ��� v 7 Area r + <br /> Pit or Grout Inspection by Date Final Inspection by Date f` - <br /> Additional Comments: t/0 r l -,( <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 /> k <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO CASH DATE PERMIT'NO. <br /> 'j <br /> + EH 14-24 fREV.t i x 5) J <br /> EH 14-26 <br />