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APPLICATION FOR PERMIT <br /> rk { SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1601 E. FiAFO AVE., STOCKTON, CA � <br /> Telephone {2091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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 /> ( +�i1' J+�iur/ aoo - Cit Si e ?�7— <br /> Job Address , jf h 10 O.•_ '•f' <br /> Address Phone <br /> Owner's NameSIC Ca S�1 <br /> Address y © +� �ktill�f License No�' . Z+��-3Phane_ �r <br /> Contractor , <br /> ELLd WELL REPLACEMENT ❑ DESTRUCTION ❑lTYPE OF WELL/P4,,Mphif��: / <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER 01 <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 T <br /> ❑ In ustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. 1. <br /> f Well Casing <br /> Domestic/Private 11 Gravel Pack ❑;Tracy'} i; ) 4ype of Casing `" Specifications <br /> F1 Public Cl Other 1-1 iDefta Depth of Grout Seal %' Type�of Grout <br /> ` t� <br /> 1 I Irrigation _Approx. Depth 1 I E stern Surface Seal Install ^ f <br /> Repair Work Done Type of Pump Ltk H.P. _�� � ,t-ate Work Done <br /> Well Destruction ❑ Well Diameter ti Sealing Material (top 501 �� <br /> Depth i..— Fillef-Material-(Below.50'.)_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.,l,.` <br /> Installation will serve: Residence— Commercial_ Other i C><) <br /> Number of living units; Number of bedrooms t <br /> Character of soil to a depth of 3 feet: Water table depth' <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line f <br /> length/size t ' <br /> LEACHING LINE ❑ No. & Length of lines Total len g � ! �. <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line I <br /> r <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS D 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 cbunry ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. ! <br /> Home owner or lice ant'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 pars in such nner as to become subject to rkman's compensation laws of California."Contractor's hiring or sub contracting signature <br /> certifies the fo wing: "I ce y that in the pe rm nce of work for which this permit is issued, I shall employ persons subject to workman's compansa <br /> i <br /> tion laws of all fo nia." <br /> The applica t m for required ' s d n r ide. <br /> Signed X✓ i Title: <br /> Dat <br /> F43R DEeART T-USE ONLY <br /> Application Accepted by Date Area <br /> i ` <br /> Ira <br /> or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> ! ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma teca 823-7104' ❑ Tracy 835-6385 <br /> 7 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE <br /> fWRMIT NO. <br /> INFO y Q♦.EH 13-24{REV. a-D r <br /> EH 14-26 <br />