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d _ _ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> k <br /> (Com let� p e in Triplicate) <br /> Application is hereby made toithe 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 /> i Local Health District. s <br /> Job Address 91F �, / <br /> . Ci OC.fGOI� Lot Size <br /> i PM <br /> Owner's Name ell <br /> EN04ddress c <br /> Phone Z. 0] <br /> Contractor " Address <br /> TYPE OF WELL/P P: License No. <br /> NEW WELL C1Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER` OTHER ❑ 4 , <br /> LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION :AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE _ <br /> TYPE OF WELL � PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> El Domestic/ 1:1 Gravel Pack Dia, of Well Casing <br /> ❑ Public ❑ Tracy Type of Casing <br /> ❑ Other ❑ Delta Specifications <br /> ❑ Irrigation � t Depth of Grout Seal Type of Grout <br /> _ lpprox. Depth ❑ Eastern --Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H P. <br /> Well Destruction ❑ State Work Done <br /> WellDiameter Sealing Material hop 50') r <br /> Depth Filler Material {Below 50'} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is <br /> I <br /> Installation will serve: Residence Commercial_ Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> i <br /> Character of sail to a depth of 3 feet: <br /> SEPTIC TANKType/MfWater table depth <br /> g <br /> PKG. TREATMENT PLT. ❑ 11 Capaci tyNo. Compartments <br /> i Method of Disposal <br /> Distance to nearest: Well Foundation <br /> �h Property Line , <br /> LEACHING LINE ❑ No. & Lengthof lines f <br /> FILTER BED k Total length/size <br /> ❑ Distance to nearest: Wel! Foundation <br /> I� o Property Line fy, <br /> SEEPAGE PITS - - - " - <br /> ❑ De1.pth Size <br /> SUMPS - <br /> ❑ _Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ '� Property Line <br /> 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 <br /> certifies the following: pehis pen laws of California."Contractor's hiring or sub contracting signature <br /> g: "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- <br /> #ion laws of California." IC <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X '. <br /> lis-47--"'. ­Titl@: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ��M. �o- t -7 <br /> i Date CJ 1 Are <br /> Pit or Grout Inspection q Dat <br /> 110 Final Inspection by Date3- <br /> 1Aft <br /> Additional Comments: I <br /> [1 Stk Lodi 369- <br /> Stk 466-6781 it <br /> 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 /> INFO A;WT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED By DATE PER IIT`NO. <br /> + EH 13-24 1 REV,1/8 s l x <br /> EH 1426 �� <br />