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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 Sari 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 19.CZ_,Jc 111__ I-G�Sr=r r elCity�_ Lot Size' -Z41 �`�G PM <br /> Owner's Name [I ___-[�al Ct _ Address ILLS��?c1 1 1_ i,r' E r -r L ,k- <br /> 1 <br /> <\ i % 1 <br /> Contractor -1 f <br /> Address -74 ate No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION (i_ <br /> -- ---- -- ilk <br /> PUMP INSTALLATION (] SYSTEM REPAIR ❑ OTHER)Q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __. DISPOSAL FLD._ PR66r. LIN <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i 1 Industrial Ll Open Bottom (1 Manteca Dia. of Well Excavation11++C,^'r ►AJDia. of Well Casing � <br /> [1 — <br /> (I Domestic/Private U Gravel Pack Tracy Type of Casing " �r 'iC, Specifications <br /> Public 11 Other 11 Delta Depth of Grout Seal '`z T/y�pe of Grout <br /> Irngauon -_--. Approx. Depth I I Eastern Surface Seal Installed by Lxre ,L 11�1, i�� <br /> Repair Work Done i? Type of Pump H.P. State Work Done _ <br /> Well Destructio ❑ Well Diameter F) Sealing Material (top 50') C C nn1- <br /> Non%Acr%, 1 An Depth - Filler Material (Below 501 <br /> TYPE OF SEPTIC . NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION.1 I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial — Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK L1 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property L,lne L <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 1­1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size _ Number <br /> SUMPS I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 1 1 <br /> 1 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." A l <br /> The applic m st call f all re re inspections. Gompiele�avi �r°"'� 'r`� ►l}T <br /> Signed Title: laa _ <br /> �- ,/ CSI / Date: <br /> � N�� OH DEPARTME �USE ONLY / <br /> Application Accepted by Date 3a fig Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> O Stk 466-6781 ❑ 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 95201 <br /> EE AMOUNT DUE INFO CASH AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> EH 132A(REV <br /> 7 <br />