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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 welt/pump and the Rules and Reguiations of the San Joaquin <br /> Local Health District. f} �,r <br /> .lob Address <br /> TflQ W e— ' 1 J tU u'1 Lot Size PM <br /> �F Owner's Name � �� Address Yoder Y'^'�' ud� Phone <br /> Conti tJr'r "� Address �� License 1Vo. 9 / � <br /> Phone <br /> F1ZTYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT a DESTRUCTION ❑ <br /> PUMP INSTALLATION •YN SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� <br /> ❑ Industrial 0pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing `�3 <br /> ❑ Domestic/Private © Gravel Pack ❑ Tracy Type of Casing S� Specifications It,O'DX <br /> i'I Public fl Other i l Delta Depth of Grout Seal Type of Grout <br /> I Gkttriyation 5-1-08 <br /> -Approx, Depth l I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pumpt'QRLyk, H.P. !3� ___ State Work Done <br /> li F; Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material 03elow 501 <br /> TREPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i <br /> r available within 200 feet.) <br /> f Installation will serve: Residence.— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 f t: Water table depth <br /> SEPTIC TANK ❑ Type/Mf Capacity No. Compartments <br /> F4 PKG. TREATMENT PLT. O Method of Disposal <br /> Distance ton rest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of\Iies Total length/size <br /> FILTER BED ❑ Distance to nearWell Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> F 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 i <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 is <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 /> e <br /> tion laws of California." <br /> The pplicant m s call fo all r uir inspections. Cogrplete drawing an verse side I' <br /> i <br /> �� d� I <br /> Signed Title: Date i <br /> tI <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Application Accepted by Date ` Area ' <br /> F Date Final Inspection by Date Q V 7 ? <br /> Pit or Grout inspection by <br /> i <br /> Additional Comments: <br /> Eli' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 D Tracy 635-6385 I <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> i <br /> FEE T AMOUNT R ITTED CK RECEIVED BY DATE PER <br /> NO. <br /> INFO AMOUNT DUE CASH <br /> . . <br /> \ <br /> 141REV,iin51 <br />