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ri ) <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �j 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> t Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> t (Complete in Triplicate) <br /> Application is he <br /> ieb made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> y <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for wetllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. - / <br /> r <br /> o-2-117o7 5 xjeil Lot Size PM <br /> City <br /> Job Address <br /> ' f =OWELL <br /> Phone <br /> I t Owner's Name � <br /> /(�g,n/`GLicense No.���Phone <br /> Contractor REPLACEMENT ❑ DESTRUCTION ❑TYPE OFWELL] U P: NEW WELL OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ industrial Q Open Bottom C; Manteca Dia. of Well Excavation <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout - <br /> 9i M Public FI Other n Delta Depth of Grout Seal <br /> I I'Irrigation _.Approx. Depth i I Eastern Surface Seal installed by <br /> Repair Work'Done ❑ Type of Pump H.P. State Work Done q <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Filler Material (Below 50'1 <br /> Depth ..� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i.l REPAIRIADDITION I DESTRUCTION l i aNailabperwahin 200 teeti1led if public sewer.1s <br /> Installation will serve: Residence`� Commercial— Other j <br /> Number of living units: Number of bedrooms I^ <br /> �, Character of soil to a depth of 3 feet: <br /> PQ/�L Water table depth V ' <br /> SEPTIC TANK ❑ Type/Mfg �. Capacity - No. Compartments. <br /> r T Method of Disposal <br /> PKG. TREATMENT PLT. ❑ / <br /> Distance to nearest: Well .. Foundation L49 Property Line <br /> 177 <br /> e <br /> LEACHING LINE Cl No. & Length of lines Total length/siz <br /> _ r� r. r C`/ <br /> FILTER BED ❑ Distance to nearest: ' Well ..- Foundation ._ Property Line_G5� <br /> SEEPAGE PITS I 1 Depth Size Number <br /> f SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> a <br /> �t 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, an <br /> rules and regulations of the San Joaquin Local Health District. <br /> ify that in the performance of the work far which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I cert <br /> ompensation laws of California." Contractor's hiring or sub contracting signature <br /> employ any person in such mariner as to become subject to workman's c <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 /> . <br /> lion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on rove e side. <br /> Signed X_��A7 <br /> Title: - Date: <br /> } OR ARTM NT U E ONLY / 2 <br /> Date <br /> Area <br /> Application Accepted by <br /> r f <br /> j Pit or Grout Inspection by <br /> Date Final Inspection by Date/ <br /> Ag*�� <br /> Additional Comments: <br /> C3 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton AveCK ., P.O. Bax 2009, Stk., CA 95201 <br /> +++ FEE AMOUNT DUE AMOUNT REMITTED CASHf7tg_ <br /> BYE PERMIT NO. <br /> INFO EH 13-24.4REV.I/A 51 9 <br /> EH 14-28 % -- - <br />