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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> { 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> f Telephone (209) 466-6781 -" <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED { % <br /> (Complete in Triplicate) yY <br /> F t' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereiW2�� lication is <br /> 'sCF1b&d:;Tliis•app <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No.'1862 for well/pump and the Rules and Re �rla'tlonsbt,the{San Joaquin <br /> Local Health District. <br /> 1�15 Ig .+' <br /> 4 •F+► <br /> Job Address L4 -� City y Lot Size PM`: <br /> n,.- <br /> Owner's Name 4' - G Z-fn Address Phone <br /> Contractor^ ? w Y fit.[ Address License No. Phone <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 /> .'_FOUNDATION AGRICULTURE WELL OTHER WELL- PITS/SUMPS <br /> !INTENDED USE TYPE OF WELL '-,PROBLEM AREA. CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Ria- of Well Excavation Dia. of Well Casing <br /> ❑'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public n Other it Delta Depth of Grout Seal Type of Grout <br /> I t Irrigation _..Approx. Depth- #-I faster.n-­-"--,< -Surface Seal-Installed by-- - -- �• - - - <br /> Repair Work Dane 17 Type of Pump H.P. + State Work Done <br /> "Well Destruction ❑ Well Diameter Sealing Material <br /> , i Depth Filler Material (Below 1 <br /> Y!TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if`public sewer is <br /> -- -..available-within 200-feet,)-- <br /> y .. Instailation,will serve: Residence Commercial— Otheroc �' ��} ^o� 6'CTr <br /> Number of living units: Number of bedrooms T ��� ` <br /> Character of soil to a depth of 3 feet: fi •'` Water table depth k <br /> r . <br /> SEPTIC TANK.1, ❑ Type/Mfg Capacity No.'l~ompariments <br /> PKG. TREATMENT PLT. ❑ �' .� Method•of Disposal. <br /> r.- . <br /> s Distance fo nearest: Well, `I -Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines „ Total length/size <br /> FILTER BED'.+ ❑ °Distanceto nearest:. Well ­IFoundation Property Line <br /> SEEPAGE PITS 1 Depth Size t Number <br /> SUMPS Cl Distance t6 nearest: Well Foundation Property Line x``;• 1/1� <br /> t DISPOSAL PONDS ❑ <br /> I hereby certify that°I haveprepared 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 Di§trict. <br /> Home owner or licensed agent's signature certifie's the following: "I certify that in the performance of the work for which this permit is-issued;_)shail not <br /> employ any person in such manner as to become subject to workman's compensation laws of California:" Contractor's hiring or sub-contrattingJsignature <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 /> The applicant must call for ail required inspections. Complete drawing on reverse side. <br /> Signed X It�3Lf�1 � Title,.4 /fir�l.A,e-tr -__ Date: <br /> R D �RTMENT USE ONLY <br /> Application Accepted by �aJ n... G��.u�T Date - � A <br /> Pit br Grout Inspection by Date 1 Final Inspection by <br /> f Additional Comments: <br /> C ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83576385 w <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.,Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK A _ RECEIVED BY DATE PERMIT'NO. <br /> +.EHt3-2IREV.5ins1 <br /> EH 71-28 <br />