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n 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 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> r 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 7 fy /1� City Lot Size '_I—T— <br /> PM <br /> ! Owner's Nameddress Phone <br /> € r. <br /> Contractor ;Ja Address { ^ !/' <br /> icense No. ®Z^. <br /> Se- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA .MENT ❑ DESTRUCTION ❑ <br /> t 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 PROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CA1 <br /> ❑ Domestic/Private; ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public y -:•. ❑ Other C) Delta Depth of Grout Seal ' <br /> I I Irrigation A Type of Grout ��-` ' p <br /> • �. pprox. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H p - <br /> State Work Done <br /> 11 1 Well flestruction O Well Diameter Sealing Material {top 501 <br /> Depth Filler-Material f elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitte4. <br /> ,if public sewer is z <br /> — <br /> Installation will serve: Residence Commercial ther_ r, ' available within 200 feet-) <br /> Number of:living units: Number of begWooms <br /> Character of soil to a depth of 3 feet: - <br /> SEPTIC TANK ❑ T Water table depth <br /> Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal i <br /> Distance to nearest: Well�^�,"Foundation- �d Property.Line t2 <br /> LEACHING LINE No. & Length of lines <br /> Total length/size ! <br /> t FILTERBED ❑ Distance to nearest: Well <br /> -_. Foundation�� r -_ property Line ._ <br /> SEEPAGE PITS ( I Depth Size �Z <br /> Number <br /> SUMPS Ll Distance to nearest: Well_ L Foundation_/�® � Property Line <br /> DISPOSAL PONDS ❑ p <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 />�r rules and regulations of the San Joaquin Local Health District- <br /> 0Home 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 certifythat in the performance of the work for which this permit is issued,I shall em l0 <br /> F t p p y persons subject to workman's compensa- <br /> tion laws of California." <br /> i i; <br /> The aipl7tmust all r all re fired i pections. Complete drawing on reverse sidle. <br /> Signed X Title: bate: J � I <br /> FORD PARTMENT USE ONLY <br /> Application Accepted by <br /> F Date Area <br /> i /�jE or Grout Inspection by 1ate Final Inspection by 1 J <br /> (� iDate <br /> r Additional Comments: <br /> r, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> c FEE AMOUNT AMOUNT REMITTED U <br /> INFO CASH RECEIVED BY DATE PERMIT'N0. <br /> �.EN13-24IREV�I H5) <br /> EH 14-2e 76 ' <br /> � r� 12-)3—Ar P7-3 -If 0 <br />