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!-e <br />d - . <br />APPLICATION. FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZEL ION AVE., STOCKTON, CA <br />Telephone (209),466-6781 <br />PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED <br />(Complete in Triplicate) 253-3`M--1 2 <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 we <br />Local <br />and the Rules and Regulations of the San Joaquin <br />Local Health District. <br />>i,� �- <br />Lot Size PM <br />Job Address City <br />Address <br />Phone <br />�!1%9f ei ' <br />C� �il �n�t h !'e.�e. �!i f0� <br />TYPE OF WELL/PUMP:' NEW WELL Cl WELL REPLACEMENT ElDES I HUL I JUN L <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ` OTHER Q <br />r ' PROP. LINE <br />SEWER LINES DISPOSAL FLD.�, # <br />DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br />rni IMneTInN AGRICULTURE WELL OTHER WELL <br />INTENDED USE <br />❑ ,Industrial - <br />❑,'Domestic/ Private <br />❑ Public <br />❑ Irrigation <br />Repair Work Done ❑ <br />Well Destruction ❑ <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Open Bottom °"' El Manteca- -N Dia. of Well Excavation <br />Q Gravel Pack ❑ Ti,acy I t Type of Casing <br />❑Other <br />�• ❑ Delta 1,1 Depth of Grout Seal <br />_t.< t <br />u- , <br />__4ppr0x. Depth Q Easternls {Surface Seal installed by <br />Type of Pump M.P. State Work Done <br />Well Diameter Sealing Material (top 501 <br />Depth K Filler Material iBelow 50'1 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑`(No septic sh erri�permitt d i�f{publ� i; c sewer i �- <br />availab e_vit in 2 .feet 1 <br />Installation will serve: Residence _/__ Commercial—Other <br />Number of living units: — Number of bedrooms' j <br />b ' — Water table depth <br />Character of soil to a depth of 3 feet: f—�`-- <br />SEPTIC TANK Type/Mfg <br />Capacity No. Compartments <br />I Method of Disposal � <br />PKG. TREATMENT PLT. ❑ ^r <br />Distance to nearest: -Well Foundation Property Line <br />LEACHING LINE ! No. & Length of lines �y /-7— Total length/sizer <br />I FILTER BED Distance to nearest: tJeli Foundation Property Line <br />Z 7 <br />SEEPAGE PITS D Depth Size � Number <br />�. <br />SUMPS i Distance to nearest: Well Foundation.12192 <br />= Property Line i <br />DISPOSAL PONDS ❑ _ '`� <br />I 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. i <br />t Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit ;s 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 issued, l shall employ persons subject to workman's compensa- <br />tion laws of California." ! <br />E The applicant must call for all quir spections. Complete drawing on reverse side. r <br />i f <br />l Signed Title: _ « Date: <br />r USE ONLY FOR DEPARTMENT U <br />} -/ 67 <br />i <br />Application Accepted by Date <br />Area <br />PP , <br />1 Date <br />Pit or Grout Inspection by 4 Date Final Inspection by <br />Dia. of Well Casing. <br />Specifications <br />Type of Grout <br />Additional Comments: ' ' ' <br />❑ Stk 466 -Ml ❑ Lodi 1369-3621 ElManteca 823-7104 ❑ Tracy 8356385 ' <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />FEE.SCK RECEIVED'8Y' DATE PERMIT'NO. <br />{NFO AMt,,, DUE AMOUNT'REhAITTEO CASH <br />r EH 13-241REV. 10!631 <br />EH 14-28 <br />