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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE`v T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR 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 Jloaquin County Ordinance No.549 for sewage or No. 1862 for woupump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> size Pl1A <br /> Job Address --.T�--, `� r e "i• 6 <br /> Phone <br /> Owner's Name �- ' )111 QtI� Addrei s <br /> p <br /> Contractor <br /> T C Addresss t- License No. 8 Phone CJ . <br /> TYPE OF WELL/PUMP: NEW WELL 171WELL REPLACEMENT ICI r. DESTRUCTION 13�I SYSTEM REPAIR I❑ OTHER El <br /> PUMP INSTALLATION Elr"- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER;LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ;OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS <br /> [D Industrial ❑:Open Bottom © Manteca " Dia. of Welf-Excavation <br /> Dia. of Well Casing <br /> I if, ....-.. ', Specifications <br /> ❑ Domestic/Private ❑"Gravel Pack '0•Tracy" Type of Casing - <br /> FI Public 171 Other F� Delta I Depth of Grout Seal Type of Grout <br /> ° I I Irrigation -=Approx.-Depth, 4 I Easternsurface Seal Installed by <br /> Repair Work Done ❑ Type of Pump I f State Work Done <br /> Wel! Destruction ❑ Well Diameter ; -Sealing-Material atop 50'1 F , <br /> 4 # Filler Material (Below 50'I <br /> Depth- <br /> TYPE OF SEPTIC WORK: ANEW INSTALLATION 1:1 REPAIR/ADDITION STRUCTION l 1 (No septic sys;11, tem permitted if public sewer is <br /> ��.--�-- .,,f available within 200 feet.) <br /> ! Installation will serve: Res i ante commercial Other' <br /> r <br /> ' Number of living units: Number of bedroomsIt; <br /> 3 f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑'(,Type/Mfg:,' c » �I Capacity� No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ P"d"`"L C""0,1xCrE;I <br /> 'Distance to nearest: Well` Foundation Property_Line <br /> LEACHING LINE L�-�No. & Length of lines Total length/size <br /> ` <br /> FILTER BED ❑ I Distance to nearest: Well Foundation Propert <br /> SEEPAGE PITS l. I`� Depth Size Number <br /> SUMPS Ll Distance to nearest:' Well` Foundation Property Line <br /> r <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 L,- <br /> rules <br /> rules and regulations of the,San Joaquin Local Health Di§trict. , } <br /> Home-owrier or licensed agent'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 person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cert es the following:"I certify that in the performance of the-work for which this permit is issued, l shall employ persons subject to workman's compensa <br /> Ilion a -f California." I1 <br /> The appiican t cal pail r uired i 'specti ns: Corn a drawing otYOaversa"si e. <br /> Title: Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> A <br /> ---^--❑-Stk-466=6781--• -El-Lodi- 369-362"1 ^�^^'6-Manteca-�8234104�^—E]Tracy-835=6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601'E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> " FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMWNO. <br /> INFO CASH <br /> +.EM 13-24(REV.riRsl <br /> - - -� <br /> EN 14-26 <br /> I� _ <br />