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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 /> (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. L6� 3 <br /> Job Address /p , �c�/�E,��Js _ City Al c- .Lot Size le PM <br /> Owner's Name 0- Address O G Phone t 06 15--101 <br /> Contractor's Name License No.� �� 6 � T Phone 6l 3 <br /> ­TYPE OF-WELL/RUMP:.--_w._..._ -NE1MaWELL -❑ r-WELL-REPLACEMENT E9, <br /> -DESTRUCTION-0— <br /> I <br /> DESTRUCTION-❑1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER la <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 pia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack El-Tracy •�Type of'Casing-i Specifications' _ <br /> ❑ Public © Other 0 Delta e`Depth of Grout Seal' Type of Grout• <br /> ❑ Irrigation ---Approx. Depth C7 Eastern 'Surface Seal Installed by <br /> Repair Work Done L3 Type of PumpH.P. 5 State Work Done <br /> Well Destruction ❑ Well Diameter <br /> .w Sealing_Material Itop.50')w. M <br /> Depth Filler Material (Below 50') W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONX REPAIR/ADDITION E DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) t <br /> Installation will serve: Residence Commercial_ Other : 3 <br /> Number of living units: Number of bedrooms ,_ ' <br /> Character of soil to a depth of 3 feet: Water table depth + i <br /> SEPTIC TANK ❑ Type/Mfg '"' ' '� `' '` <br /> Capacity No. Compartments ' <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> f7istance to nearest: Well Foundation property Line <br /> LEACHING LINE No. & Length of lines 1 Total lengthlsize <br /> FILTER BED ❑ Distance to nearest: Well FoundationProperty Line <br /> SEEPAGE PITS ❑ Depth Size ' Numbertir" S- <br /> SUMPS <br /> ❑ 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 Sari 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.-bf the wort 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."Contractors 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.' <br /> The applicant must call for all1equirV inspections. Complete drawing on reverse side. f s <br /> i <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 1tv, Date Area 40 7 _ <br /> Pit or Grout Inspection try Date Final Inspection by A.0, $4V Date 0---d-"f37 <br /> Additional Comments: i <br /> ❑ Stk 466-6781 ,❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. <br /> INFO CASH <br /> + EH 13.24(REV.101831 <br /> EH 14-26 <br />