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i <br /> APPLICATION FOR PERMIT <br /> I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �J 1601 E. HAZELTON AVE., STOCKTON, CA <br /> n L Telephone (209) 466-6781 <br /> # [J a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 0 2_5'— 02-0—0L/ <br /> �(°5:.7�q nJ • �--i�s sc�cam-i2/� • , <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 sewagew NO.. 1862 °r well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> + Job Address City Lai Size PM <br /> Owner's Name Address 4. <br /> k Phone'' ' <br /> " Contract v6Address (cense No Phone <br /> .TYPE OFELL/ NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION F)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 /> i INTENDED USN TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 3, ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private \❑ Gravel,Pack ❑ Tracy Type of Casing _Specifications <br /> F] Public R Other -�, —.I 1,Delta"'-""'" Depth of Grout Seal � A � Type of Grout � <br /> I i Irrigation �Approx. Depth I ] Eastern Surface Seal.lnstalled by n <br /> j Repair Work Done ❑ Type at Pump H,P. State Work Done <br /> !Y) <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> ­TYPE OF SEPTIC WORK: NEW INSTALLATION . REPAIR/ DITION E I DESTRUCTION I 1 fNo septic system permitted if public sewer is i <br /> available within 200 feet.) <br /> Installation will serve: Residence__Y__-Commercial Other <br /> Number of living tynks:=1 Number of bedr ms v <br /> .Character-of soil [o-a'depth,of 3 feet: Water [able depth <br /> SEPTIC TANK t ,,-❑_Type/Mfg Capacity L No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of�7Dispglal <br /> __.Distance_to,nearest:_We11- Foundation Property Line __a___.,� <br /> l LEACHING LINE ❑ No. & Length bf lines Total length/size <br /> FILTER BED ❑ distance to'nea?est: WeII,O i Foundation Property Line <br /> SEEPAGE PITS l 1 Depth Size Number <br /> F SUMPS i L] Distance to nearest: Well Foundation Property Line T <br /> DISPOSAL PONDS 1 "❑ <br /> 1 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 /> I The applica u all for all re i d inspection Cc plate drawing on rerse side. <br /> Signed X Title: [ Date: <br /> I <br /> FOR DEPART NT USE ONLY <br /> 1 Application Accepted by .Date ,--- _2Area <br /> F Pit or Grout Inspection by D to Final Inspection bV Date <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. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK 0 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> r - INFO — <br /> + EH 13-24(REV.i/n 51 <br /> EH 14 24 <br />