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APPLICATION FOR PERMIT <br /> SAN JOA, OUIN 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 /> (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. "''� <br /> Job Address 96.C)3 + '`� S�T T 8 r - f <br /> 1 City <br /> Lot Size � � PM <br /> Owner's Name - 13452 ()P'.cr,��2 Address 663 ' Q nIVII-1 <br /> ��jj --�� Phone �—'.. <br /> Contractors Name KbTp RoO eg License No. _. L7 • .� Phone ^!�J <br /> TYPE OF WELL/PUMP: ...NEW WELL E] WELL REPLACEMENT-_❑ ,xDESTRUCTION..❑ <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 ;l <br /> ❑ Domestic/Private ❑ Grave( Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout----- <br /> El <br /> rout ----❑ 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 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION'Iff DESTRUCTION ❑ (No septic system permitted if public sewer is 6- <br /> X. <br /> X. available within 200 feet./ <br /> Installation will serve: Residence_X Commercial 3 Other <br /> Number of living units: Number of bedrooms V`r <br /> Character of soil to a depth of 3 feet:— A baa- Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line 1 <br /> LEACHING LINE, No. & Length of lines Qyv— 40 Total length/size0 r <br /> FILTER BED W ❑ Distance to nearest: Well AM _ Foundation 3 6 Property Line <br /> SEEPAGE PITS 12' Depth ` Size M Number <br /> SUMPS ❑ Distance to nearest: Well Foundation acs f Property Line <br /> DISPOSAL PONDS ❑ <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 laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:.':(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 applicant must call for all require i ons. ple,a drawing on reverse side. �J �/ <br /> Signed itle: . �� !_._r; X - J <br /> ,~Date: _ <br /> FOR DEPARTMENT USE ON <br /> i <br /> Application Accepted by Date ^ Area <br /> Pit or Grout Inspection by Date''Final Inspection-] _epate � <br /> Aditionai Comments: _ <br /> Stk 466.6781 ❑ Lodi 1 ❑ Manteca 823-71 _ ❑ Tracy 83x6385 <br /> plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> F EE <br /> INFO M/O[U(NTDUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV-10!83) <br /> EH 1428 �/ 9 <br />