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i <br /> z= APPLICATION FOR PERMIT _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 ��] City sT� D,cLdt Size PM <br /> -ti <br /> ,/�� Q <br /> ,, _Owner;s.Name. hyU� __ Address �C� i �.�/���l�i f�f� _ _ Phone <br /> _ -- Y.�:. a <br /> Contractor �y, Address rLicense No.�h'B/G� ('hone <br /> TYPE OF WELL/PUMP: ` NEW WELL;R? H i WELL',REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIONq7 �/ SYSTEM R PAIR Li- - OTHER ❑ <br /> -bISTANCETONEAREST`"SEPTIC'TATQK�� —S WERLINES' ` '¢9" DISPOSAL-FLD:- -PROP-LINE-= -� <br /> fJRl1Y y ,FOUNDATION. r { AGRICULTURE WELL CHER WEL"L� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA­CONSTRIJCT10W-SPECIFICATIONS----: !� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.Yof=Well Excavation te100 l' Dia. of Well Casing <br /> Domestic/Private ,j$?Gravel Pack r7 Tracy Type of Casing Specifications <br /> F" Public ❑ Othler C Delta _ Depth of Grout Seal _-5�9 Tyke of Grout <br /> I I Irrigation __ pprox. Depth. II II Eastern i Su ace Seal Installed by <br /> Repair Work Done L1Type d5f Pump _.[!.�� H.P. � � State Work Done _ Q <br /> •aV; <br /> Well Destruction ❑ Well Riameter Sealing Material {top 501 r <br /> Depth) Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION 1 1 (No septic system permitted if public sewer is <br /> available withih 200 feet) <br /> Installation will serve: ResideAce_ Corftmarcial <br /> Number of-living units: }€ Number of bedroomsrc��� <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. ❑ IMethod of Disposal <br /> Distance to nearest: Well Foundation - - Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size. <br /> FILTER BED CJ Di&lance to nearest: Well `Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS 0 Distance.to nearest: - Well Foundation Property-tine <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," i <br /> t <br /> The applicant all req �ions., e drawing on r ars Ida. <br /> Signed X� Title: Date: 101-//— OC113 r <br /> i <br /> j FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area Area a 1 <br /> Pit or Grout Inspection by f Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 368-3621 ❑ 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 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> � EH 13-24(REV.I/K 51 � / V -I�-�3 <br /> EH 14-28 f ' <br /> I <br />