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J APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA a <br /> + Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Appiicaltion is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described:This application is <br /> compliance with San Joaquin County Ordinance No.649 for sewage or No.1882 for welilpump and the Rules and Regulations of the San�Joaquin <br /> made m P �. <br /> Local Health District. - PM <br /> .- :.•".. City G-yCr.� Lot Size <br /> Job Address _ <br /> ��ldyi;2 X r Phone <br /> 1 Address <br /> Owner's Name <br /> ��7— Phone <br /> I License No. <br /> Contractor's N REPLACEMENT ACEMENT LiDESTRUCTION LJ <br /> t P1' WELL ❑ OTHER 13TYPE OF WELL/PUMP: PUMP INSTASYSTEM REPAIR *11LLATION ElpISPOSAL FLD. PROP.LINE - <br /> SEWER LINES -- PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK��- AGRICULTURE WELL OTHER WELL <br /> I FOUNDATION <br /> INTENDED USE TYPE OF WELL _ PROBLEM-AREA 'CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Bottom Manteca Dia. of Well Excavation <br /> ❑ Open <br /> ❑ Industrial , , specifications <br /> ❑Tracy Type of Casln <br /> ❑ Domestic/Private El Gravel Pack �,•- Depth of Grout Seal Type of Grout <br /> ❑ Public ❑ Other ❑ Deka <br /> ___Approx. Depth ❑ Eastern Surface Seal installed by <br /> ❑ lrrrgation _ _,State Work Done i <br /> Repair Work Done ❑ Type Of Pump `H P. <br /> . ` Sealing Material(top 501 <br /> Well Destruction ❑ Well Diameter r , Piller Material(Below W) <br /> Depth— = <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑-REPAIR/ADOI1ION ❑ IDESTRUCTION ❑ availableNselwithin 200 feetitted if public sewer is ' <br /> r <br /> Installation will serve: Residence — Commercial! Other ` <br /> r � <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments — <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> • Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines - Total length/size Z <br /> FILTER BED ❑ Distance to nearest: Well Foundation f Property Line <br /> SEEPAGE P11TS Depth _ —Si. P Plumber <br /> SUMPS El Distance to nearest: <br /> Well Foundation �--t`1 Property Line=S <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 pemlit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu all for all req /red Ing ctio is. Complete drawing on reverse side. G <br /> Signed ! Title: Date: <br /> _ FOR DEPARTMENT USE ONLY <br /> Application Accepted by /_Q��/`(/j Date Area . <br /> Pito Grout 'spection by Date WFnal Inspection by Date�Ly <br /> Additional Comments: A <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEFAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO, <br /> INFO CASH <br /> .En 13-24 WEV.10/83) 17 �f 1�11R3 <br /> E44 14-28 <br />