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I: APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601.-1. HAZEL i W AVE., STOCKTON, CA <br /> Telephones(209)-466-Ml <br /> PERMIT EXPIRES'1 YEAR`'FROMDATE ISSUED <br /> ;�r es ; . . 'I' .e., _:*+ << [Complete in.Triplicate} .. <br /> i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein dekiribed3 This ao0kawn is <br /> E made�in compliance wkh,San Joaquin County.Ordinance No 549,for.sewage,9r.No. 1862,for well/pump and the Rulss•and Regulations of the San,Joaquin <br /> Local Health DistncY , " <br /> '.11 his _sJ�= - ✓4"'. _. .{.-E <br /> Job Address ! z f ��` 1 Cityr j14 acALot Sue PM' <br /> Q <br /> Owner s Nam _,Address _S4i/h.Pi <br /> it Phone <br /> I Contractor° i Address A Zk 141 License No. Phone <br /> TYPE OF WELL/PUMP: !p NEW WELL ❑ ": ,WELL REPLACEMENT Q DESTRUCTION. ❑ <br /> • ' PUMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE,TO NEAREST:, SEPTIC TANK SEWER.LINES DISPOSAL FLD. PROP. LINE <br /> ii FOUNDATION' AGRICULTURE'WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE ' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> ❑ Industrial. ❑ Open Bottom ❑ Manteca, Dia. of Well Excavation Dia.of Well Casing <br /> li <br /> r ❑ Domestic/Private ! �❑ Gravel Pack ❑ Tracy Type of Casing_1 Specifications <br /> ❑ Public ❑ Other ❑ Deha Depth of Grout teal <br /> Type of Grout <br /> ❑ Irrigation i2Approx. Depth ❑ Eastern Surface,Seal Installed by <br /> € Repair.Work Done 0 Type of Pump: H.P: State Work Done <br /> Well Destruction- 0; Well''Diameter Sealing Material(top 50') <br /> I; Depth. Filler Material l8elow SO') <br /> TYPE OF SEPTIC WORK: NEW IN ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> 1 Installation will serve II Res-'d' ce— Commercial Other <br /> Number of living units: `I—.' Number of bedrooms 3 it <br /> Character of soil to a?depth of 3 feet: 5:A:.& .491�� Water labia depth <br /> SEPTIC TANK i' ❑ Type/Mfg Capactty•" No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal ^ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE p No."A Length of'13nes 7g1al length/size 5-el is 0 <br /> FILTER BED ,I ❑ Distance to nearest: - Well .�'l� Foundation Property Line <br /> SEEPAGE PITS a Depth Size a Number. <br /> :. SUMPS it ❑ Distanoe to nearest: ,Well Foundation �4- Property Line <br /> DISPOSAL PONDS li:❑ <br /> rules andcre certify <br /> that <br /> of San Joat uin Loco Health Distaa the work'will be'done in accordance with;San Joaquin county ordinances, state laws, and <br /> Y fY prepared application <br /> g q f q <br /> Homeowner or licensed agent's signature certifies the following: "I certify,that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person m suchmanner as to become subject to workman's c6mpensation.laws of.California."Contractors hiring or sub contracting signature. <br /> certiFis ttie"following:"I certify'thatin the performanoe'of the rirork for which this permit is issued,I shall employ persoru subject to workman`s compensa <br /> tion laws of California.'•I <br /> The applicant must call for all r�e�gjuirreed inspections. Complete dra4ving on reverse side. f <br /> Signed)L��r Date <br /> Z . <br /> ... E <br /> Date. <br /> II �� FOR DEPARTMENT USE ONLY. <br /> Application Accepted by `� Date Area © " <br /> Pit or Grout Inspection by Date +Firial Inspection by" p <br /> r Additional Comments' "a 'I <br /> ❑ Stk 466-6781 _ b,Lodi'. '369 3621 ❑ Manteca ,,823-7104 i _" .0_Tracy .835.63135 <br /> Applicant-.Return all copies to: Environmental Health Permit/Services 1601 E1 Haeltori Ave., P.O. Box 2009, Stk., CA 95201 ' <br /> INFO AMOUNT DUE •AMOUNT­REMITTED�' "'CASH `RECEIVED BY DATE WPERMIT`_NO.." , <br /> + EH 13-24{REV.i%s5) <br /> EH 1428 <br />