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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> l 1601 E. HAZE 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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> r - <br /> Job Address �'•-7 �/�� City �! c�C/p�Lot Size PM <br /> Owne?s Name �SO r) _ Address ''tom Phone-r_ Pb l5 <br /> Contractor _ SD.y Address �� 'License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER PINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 1 OTHER WELL "• _� PITS/SUMPS <br /> INTENDED USE TYPE OF DWELL:-- PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> C1Industrial %.1 QtOpen Bottom 4. ❑ Manteca Dia. of Well Excavation-- --_ -----.Dia.-of Well Casing <br /> ❑ Domestic/Private! <br /> ❑.Gravel Pack } ❑ Tracy Type of Casing Specifications <br /> * Public 1711 Other - n Delta Deptti of-Grout'S_eai Type of Grout <br /> —_­ <br /> I I Irrigation t ._ w-- -Apprgx.-Dep th l I Eastern_ Surface Seal Installed-by-- 1 <br /> Repair Work Done ❑ Type of Pump. H.P. State Work Done _ <br /> Well Destruction' ❑ Well Diameter Sealing Material (top 50') .i Cr„ <br /> Depth _ Filler Material (Below 50') 1/ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION (No septic system permitted if public sewer is <br /> y � <br /> { available within 200 feet.) U1 <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 fable depth <br /> SEPTIC TANK Type/Mfg r7 pp, p. 2— , <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ t-► Method of Disposal <br /> Distance to nearest: Well Foundation J Property Line <br /> LEACHING LINE ❑ No. $ Length of lines `1 I Total length/size <br /> FILTER BED ❑ Distance toynearest: Well ' Foundation <br /> Property Line <br /> k t <br /> SEEPAGE PITS Depth Size S Number 'Z <br /> SUMPS D Distance to'nearest: Well "' Foundation Property Line <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 <br /> rules and regulations of the San Joaquin Local Health District. `, <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the perfotm'anceof 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 /> certifies the following: "I certify that in the performance of the work for which this permit is issue , shallemploy persons subject to workman's compensa- <br /> tion laws of California." dI I <br /> The applicant must call for all required inspections. Complete drawing on reverse side. ' <br /> Signed X '-- �q <br /> Title: : tiA� Date: d <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byDate�. <br /> A � Area <br /> Pit or Grout Inspection by Date Final I�ct1� ° <br /> Date ; <br /> Additional Comments: 41")- <br /> E <br /> /)❑ Stk 466-6781 \ D.Lodi 3621 ❑ Manteca 823-7104 p Tracy 835-6385 <br /> Applicant- Return all'Copies to:;Envir6nmental Health Permit/Services 1601 E. Hez ton Av ., P.O. Box 2009, S ., CA 95201 i <br /> r FEE. AMOUNT DUE --AMOUNT-REMITTED - CK- <br /> INFO CASH ^—RECEIVE6-6Y—---DATE PERMIT'NO. <br /> EH 13-24 //fl�//y <br /> (�]��] <br /> i EH 14-28 /H5)t/H5f -7d L'1+ <br />