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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> f Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) \%C6 <br /> as <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal k herlain cribed. T. .application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and t �ulesle lvegulatiogs 3f*San Joaquin <br /> Local Health Distric ���a'•'��w <br /> Job Addresses City Lot Size ��� PM <br /> Owner's Name ill 1 <br /> �Tdr.I 5AA4-- Phone <br /> Contractor �4 ddress Z « License No.A%_61-0Phone b <br /> TYPE OF WELL/-PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR❑ OTHER B- nPV%e <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> "FOUNDATIONAGRICULTliRE WELL` r OTHER WELL' PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑,Open Bottom ❑ Manteca Dia. of Well Excavation '4- Dia. of Well Casing <br /> r <br /> ❑ Domestic/Private ❑ GravelPac{k Cal'acy Type of Casing Specifications <br /> f 1 Public ( 'Other 6V Delta Depth of Grout Seal Type of Grout fry <br /> ,I I Irrigation i fl l_Approx. Depth I I 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 <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic.system permitted if public sewer is <br /> r available within 200 feet.) ;�J <br /> Installation will serve: Residence— Commercial_ Other �� <br /> Number of living units: Number of booms <br /> Character of soil to a depth of 3 feet!: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well fou ion Property line - �4 <br /> I <br /> LEACHING LINE ❑ No. & Length of lines otal length/size <br /> t FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> z <br /> SEEPAGE PITS I I Depth l Size Number <br /> 1 <br /> SUMPS ❑ Distance.to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS' a Q ­­4­, .. f - ----Q ;i;- —i - -r.. ,- <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. C) <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 lapoforniaThe apt call for �eqinspections. Complete drawing on verse side. r <br /> Signed Title: .6 1� Date: la—j-2 <br /> -2 v�� <br /> FOR d MENT USE ONLY <br /> Application Accepted by Date //EfgArea <br /> Pit or Grout inspection by Date �Final inspection by Date <br /> Additional Comments: _- ell Q <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 f ❑ 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 /> FEECK <br /> W v INFO AMOUNT DUE "AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. <br /> +.EH 13-24 I REV.t i n5) l T - � 4f- - <br /> EH 14.28• L.7 <br />