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APPLICATION FOR PERMIT <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT t/ <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i 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 /> Job Address �i4ZR-tfl <br /> r CityLot Size PM <br /> Owner's Name � +std. / O <br /> ?�'CAddress r � -� �r� Phone3;211 <br /> Contractor 52� Address <br /> License No. Phone <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.-'--"---F •PROP-LINE – <br /> FOUNDATION AGRICULTURE b11ELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 'Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (T1 Public Cl Other 4 Ll Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation —._Approx. Depth f I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ Y <br /> Well Destruction ❑ Well Diameter Sealing Material atop 50') <br /> Depth Filler Material [Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRUCTION 1 iNo septic system permitted if public sewer is <br /> ailable within 200 feet.) <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:r Water table depth <br /> SEPTIC TANK- ❑ Type/Mfg! Capacity No. Compartments <br /> PKG. TREATMENT PLT- ❑ i Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth s Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i <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 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 /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ' $ <br /> The applica t rst call or all re uired inspections. Complete drawing on reverse side. t <br /> r a <br /> Signed X Title: Date: p k <br /> FOR DEPARTMENT USE ONLY � <br /> Application Accepted by / <br /> Date Area <br /> Pit or Grout Ins 7 <br /> pection Date Final Inspection by Date <br /> Additional Comments: v <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 C7 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 /> FEECK <br /> INFO AMOUNT DUE AMOUNT REMITTED C SH RE VED BY DATE PERMIT NO. <br />,�, EH 13-241REV,rix5l �} _ �a7� J 3a, <br /> EH 14-28 r� <br />