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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 <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. c� ii <br /> Job Address + /� City S c/(7_0 Lot Size !02/ Rs PM <br /> Owner's Name V N C T SZAddress SA-M -e_ Phone <br /> Contractor's Name 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. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 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 r� <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i <br /> ❑ Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction . ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) , <br /> Installation will serve: Residence 4 Commercial_ Other l <br /> Number of living units: --I— Number of bedrooms ? / <br /> Character of soil to a depth of 3 feet: � _�r4!ut - �.�/4 y Water table depth <br /> SEPTIC TANK ❑ Type/Mfg #'5 n,At e Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines / — �/e3 I _ T/ptal length/size <br /> FILTER BED I] Distance to nearest: Well lao Foundation_.,7.__ Property Line s- <br /> SEEPAGE PITS ❑ Depth JT ,Size 33 _/Number f1 <br /> SUMPS ❑ Distance to nearest: Welles Foundation/40 -74 Property Lin <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 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."Contractors 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 app7==77i:7 <br /> lete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY _ <br /> Application Accepted by �`'� r I Date Y Area <br /> Pit or Grout Inspection by Date S-fq- � Final Inspection byw, DateSa34 <br /> i <br /> Additional Comments: <br /> XStk 466-6781 ❑ Lodi 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 /> a <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH1324(REY.10!63) -� - Lis , a _ 5�` (']. g <br /> EH 1426 6� ���O <br />