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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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.548 for.sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 3 l Qy, + amity C�Yom\ Lot Size_S/k A ct­,-�PM <br /> Owner's Name �Address Phone i <br /> Contractor's Name wd��`� /�I 'L/a/,�S nse No. alo-T 514 Phone 6 c4 ` <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION`, <br /> ,• PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ OC <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 /> i <br /> ❑ Industrial ❑ Open Bottom ❑.Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout h(� <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 (top 501 0 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ;No septic system permitted if public sewer is <br /> available within 200 feet.) F <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: Water table depth Q <br /> SEPTIC TANK ❑ Type/Mfg 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 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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."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." r r t <br /> The applicant must I fq 11 r uire inspections. Complete drawing on reverse side. <br /> Signed f itle: i.f- _ Date: - �� 00'T I <br /> / FOR EPARTMENT USE ONLY ►� ,� /' <br /> Application Accepted by Date ` <br /> y "� Area—/ Y-- <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all opies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2OD9, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CAK RECEIVED BY DATE PERMIT'NO. <br /> 11 IF EH 13-24(REV,10/831 <br /> 19!831 <br /> } EH 1426 lc3 <br />