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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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. i - ,,,/ <br /> Job Address USO �aQG1f4� ' w1e— City LL/ldZ4 Lot Size PM <br /> Owner's Name r�rrodea-Tg) . QI- Address �4de4h:)- �1"��- . U�� Phone <br /> Contr iGl��, Address tP ,lyG�/�✓ License No. 99'7o� Phone <br /> ,' <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION . SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> n <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS / <br /> ❑ Industrial (h Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing <br /> F-1 Domestic/Private El Gravel Pack ❑ Tracy Type of Casing S> Specifications /4,04DX <br /> F1 Public n Other n Delta Depth of Grout Seal Type of Grout <br /> - <br /> Ir.lrriyation 530r Approx. Depth l 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump by Lk c, H.P. /alp State Work Done-&-2e")64LW f­rycd <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') ^f� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I 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 C� <br /> Character of soil to a depth of 3 f t: Water table depth �! <br /> SEPTIC TANK ❑ Type/Mf Capacity No. Compartments R. <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to n rest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length ofh es Total length/size <br /> FILTER BED El Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS 11 Distance to nearest: Well _ Foundation Property Line <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." <br /> Thepplicant tmCompletet call fo all r uir inspections. drawing on averse side <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by C-T7 Date S Area r / �� ��, <br /> Pit or Grout Inspection by Date Final Inspection bY4 <br /> DateoLL� <br /> Additional Comments: <br /> ❑ 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 95201FEE <br /> INFO AMOUNT DUE AMOUNT R TED, CA H RECEIVED BY DATE PERMIT NO. <br /> EH13.24(REV,r:x5i 3'`> L �/ <br /> EH 14-26 <br /> ey'/—/D(6 <br /> r? 17 <br />