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T APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> {, .. 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (2091466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constructan <br /> Local Health District. d/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 /> ir Job Address 4 —7 <br /> City Lot Size AM <br /> Owner's Name :54,caj- <br /> Address a �5 <br /> Phone <br /> Contractor rLLI Address ® D <br /> TYPE OF Wi7iELL/PUMP: License No. Phone <br /> NEW WELL KWELL REPLACEMENT ❑ <br /> PUMP INSTALLATION ❑ DESTRUCTION LJDISTANCE TO NEAREST: SEPTIC TANK Z.8Z' SYSTEM REPAIR L7 OTHER Ir /kOal�To12/,�l� <br /> SEWER LINES DISPOSAL FLD. PROP. LINE �0 <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom <br /> EDManteca — " <br /> Dia. of Well Excavation �-DomnsticlPrivate Dia. of Well Casing Z <br /> f�Gravel Pack ❑ Tracy T <br /> 1`7 public -1 Specifications <br /> ype of Casing G Q ' <br /> f- Other L� Delta Depth of Grout Seal I <br /> I I Irrigation 1" Type of Grout--C ,� <br /> --Approx. Depth l I Eastern Surface Seal Installed by A_. <br /> Repair Work Done L] Type of Pump <br /> _ <br /> Wel! Destruction 1-2Well Diameter H.P. State Work Done <br /> Sealing Material (top 50') t <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION !:I REPAIRJADDITION l I DESTRUCTION I 1 INo septic system permitted ifublic <br /> available within 200 feet.) p sewer is <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms I' <br /> Character of soii to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> m <br /> Ii <br /> Distance to nearest: Well Method of Disposal <br /> Foundation Property Line <br /> LEACHING LINE ❑ No,& Length of lines <br /> FILTER BED ❑ Distance to nearest: . WellTotal length/size <br /> Foundation Property Line <br /> SEEPAGE PITS l I Oepth <br /> Size Number <br /> SUMPS L-i Distance to nearest: Well <br /> DISPpSAL PONDS p Foundation Property Line <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: h <br /> employ any person in such manner.as to become subject to workman's compensation lawsofCaliforrnia." Contractor'snce of the work for 'hiringl or sub-contracting s gns permit is issued, I etnot <br /> ute <br /> certifies the following: "I certify that in the performance of the work for which this permit is issuedI shall em to <br /> tion laws of California." p , p y persons subject to workman's compensa <br /> The app"a mus all for all required i specti s. Complete drawing on reverse side. <br /> Signed pp <br /> Title: �E I �S L' Date: <br /> R DEPARTMENT USE ONLY. <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by r <br /> Date� Final Inspection by }' <br /> Additional Comments: <br /> Date <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.:Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE OUNT DUE AMOUNT REMITTED <br /> INFO CKCASH RECEIVED BY DATE <br /> PERMIT-NO. <br /> EH 13-24(REV.tin5l C ,O—ZD <br /> EH 14-28 <br />