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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-I'YEAR FROM DATE.ISSUED �. t <br /> (Complete;jn 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. . ti, iOfo^ <br /> City <br /> s r" � <br /> h G"! Lot Size1` d PM i <br /> Job Address I <br /> _ f <br /> * <br /> Ae <br /> Owner's Nam �isfle,M e/ Address -�' 'P Phone <br /> e <br /> €- �4 <br /> Contractor's Name License No.. AblM Phone <br /> TYPE OF WELL/PUMP: NEW WELL t] WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --&r- DISPOSAL FLD..//����,,���� PROP. LINE <br /> FOUNDATION AGRICULTURE WELL�`�'OTHER WELL,&AL_ PITS/SUMPS. v I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial - ❑ Open Bottom— ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private OGravel Pack ❑ Tracy Type of Casing R-1C Specifications $e Aro <br /> ❑ Public LI Other' 1:1 Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth 0 Eastern Surface Seal Installed by 1 <br /> Repair Work Done ❑ Type of Pump SA4 b H.P. State Work'Done <br /> ',Wall Destruction ❑ Well Diameter Sealing Material (top 501 <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.] V"� <br /> W�� <br /> � "Installation will serve: Residence— Commercial_ other +D Fb <br /> �Numbej of1iving units: Number of bedrooms ST <br /> j Character of soil to a depth of 3 feet: y atar table depth f <br /> $IEPTIC TANK Cl Type/.Mfg Capacity No. Compartments <br /> PKG.'TREATMENT PLT. EJr Method of Disposal <br /> _. t r A �. <br /> �• i Distance to nearest:' Well Foundation Property tine <br /> LEACHING LINE ❑ No. &"Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property tine <br /> SEEPAGE PITS ❑ Depth Size Number <br /> r;SUMPS ❑ Distance to nearest: Well Foundation 'Property Line 1 '. <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 /> " Grules and regulations of the San Joaquin Local Health District. i <br /> 'Horne 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 nbt <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: i 4- <br /> -tion laws of California." z <br /> The applicant must II for all equir�ed ins ctio ��-mplete drawing on revs a side. ' <br /> Signed Title: Dategr: <br /> FOR DEPARTMENT USE-ONLY <br /> --t.. r <br /> Application Accepted by !J Date Area ]rj <br /> ~ Date f� al Inspection by Date `r <br /> Pit o rout I spection by <br /> Additional Comments: <br /> ❑ Stk 4&6-6781 'F ❑ 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 85201 <br /> " . e FEE <br /> INFO. AMOUNT DUE AMOUNT REMITTEE} CASH RECEIVED BY DATE PERMIT"NO." <br /> o <br /> + EH 13-24[REV. <br /> EH 14.25 <br /> r s <br />