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f' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781" . N-) <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ZS <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. /� <br /> Job Address 16P�f �� 11_4ZZ .,W e— City X407"_CiFLot Size PM <br /> Owner's Name L�1e7�-� Address _A<57a3 ,4- W'r- Phone <br /> Contractor X04, 1. �1��LC� Address ;,�¢ p Z,4_License No®�2�;, A�Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 11 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 Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 4 <br /> FI Public f Other Cl Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation Approx. Depth l I Eastern Surface Seal Installed by _ <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material iBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ I-&�REPAIRIADOITION i.l DESTRUCTION (No septic system permitted it public sewer is <br /> / available within 200 feet.) <br /> Installation will serve: Aesidencee Commercial_ Other LD <br /> Number of living units: Number of_bedrooms a' <br /> Character of soil to a depth of,3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity"- ' No. Compartments <br /> PKG, TREATMENT PLT. ❑ `' '� s -Mithod of Disposal <br /> i' Distance to nearest. Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ! I I Depth�' Size Number s <br /> SUMPS L] Distancerto nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 '� f' <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 ageriYs 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 taws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify tl akin 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 fo all r wired inspections. Complete drawing on reverse side. " <br /> t <br /> Signed X Title: ��.c. _ Date- <br /> RT <br /> ate: <br /> RTMENT USE ONLY Application Accepted by `�LS.c1n1. &M­oAJ�rI"P Date Area <br /> Pit or Grout Inspection by Date Final Inspection by _ Date 7 <br /> r F <br /> Additional Comments: <br /> ❑ Stk 466-6781 t ❑ 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 20W, Stk., CA 95201 f <br /> INFO AMOUNT DUE,-c --"AMOUNT'REMITT•ED. -' - "-r` ---RECEIVED-8Y ^^^-DAT@' PERMIT'NO"' '^- <br /> x...,,. ... .<.. .. <br /> + EH1Cj r <br /> 3-24 TREY,t/x 57 <br /> EH 14-2a ' "y <br />