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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 SES' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NTAL HEALTH <br /> (Complete in Triplicate) ENVIRONMENTAL <br /> E 1CS <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor <br /> pI}�'(t�5 re 'This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welll pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> I Y ( City T Lot Size PM r <br /> Job Addressr <br /> Phone <br /> ?.V:-�7 <br /> Owner's Name" � +�������� InJI Address <br /> TA <br /> i L Address License No. .. Phone_ <br /> Contractor - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT- —DESTRUCTION-0 <br />� PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _ -- - r .. ,,...r�PITSISUMPS ^• - <br /> SEWER <br /> FOUNDATION LTURE WFLL J OTHER-WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS-; <br /> E1 Industrial Q Open Bottom Q Manteca Dia. of Well Excavation <br /> `ti. Dia. of Well Casing <br /> j Type of Casing Specifications <br /> I` Qi <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy N' Type of Grout <br /> --- <br /> 'R <br /> Public Cl Other Cl Delta Depth of Grout Seal <br /> ace Seal Installed by <br /> I I Irrigation ..Approx. Depth l 1 Eastern Surf �j <br /> ii Repair Work Done 71 Type of Pump <br /> �la$� H.P. — State Work Done <br /> Weil Destruction Ll Well Diameter Scaling Sealing Material (top 50'1 <br /> i Depth Filler Material (Below 50'1 r "� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION�I_I` DES UCTION l�vailabe within 27depth <br /> feetNo septic system .) if4,, <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms 4 � <br /> Water table <br /> I Character of soil to a depth of 3 feet: <br /> v SEPTIC TANK 0 Type/Mfg <br /> Capacity No. Compa <br /> Method of PKG. TREATMENT PLT" ❑ Distance to nearest: Well. Foundation =Property Line <br /> LEACHING LINE ❑ No. & Length of linesTotal length/size <br /> FILTER BED Q Distance to nearest: Well Foundation Property Line <br /> 1 <br /> I <br /> SEEPAGE PITS I I Depth Size Number t <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line r <br /> E-- •DISPOSAL'PONDS'. ❑ <br /> I and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> 1 hereby certify that I have prepared this application <br /> rules and regulations of the San Joaquin Local Health Dietrict. <br /> Home owner or Ii sed agent's signature certifies the following: "1 certify that in the performance of the;work for which this permit is issued, I shall not <br /> ample ow per n i such manner as to become subject to workman's compensation laws of California." Contractor's-hiring or sub-contracting signature <br /> certifies the full wi : "I certify that in the performance of the work for which this perm - issued, I shall employ persons subject to workman's compensa <br /> tion law f nia.•• <br /> inspection . Complete drawing an rev rse side. <br /> .The applic t call for all requir d) <br /> Title: Date: <br /> Signed X <br /> l <br /> FOR DEPARTM USE NLY <br /> Date Area <br /> I Application Accepted by �j <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by j <br /> i <br /> Additional Comments: <br /> —O-Stk- 466-67819-❑ L-odi 369-3621— ❑_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 /> .CKFEE AMOUNT DUE AMOUNT REMITTED CASH ~ 1 RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> 7-66 1-24'1 R E v.1/H 51 -77 <br /> EH 14-2s <br />