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4 \ <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRIC <br />D <br />1601 E. HAZEL T ON AVE., STOCKTON, CA �, 10316 <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 9 YEAR FROM DATE ISSUED 010�A� N Es <br />(Complete in Triplicate) ��VkgOv IstIR ' <br />Application is heEeby made to the San Joaquin Local Health District for a permit to construct and/or install the wotkr a <br />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 />Eob Arfrlracc�C] �o +'YJ <br />Citv..L1 Lot Size <br />PM <br />Owner's Nam ^ <br />+. K Address "/. Je" r_&_— Phone <br />C �y�� a <br />Contract Address License No. IF � Phone 's <br />TYPE OF WELL/PUMP: <br />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 <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Industrial <br />❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />Ot-vornestic/ <br />❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br />[`l Public <br />❑ Other n Delta Depth of Grout Seal Type of Grout _ <br />I I Irrigation <br />_..Approx. Depth l I Eastern Surface Seal Installed by <br />Repair Work Done ❑ <br />Type of Pump ,e@y.1��r H. P, �3 State Work Done <br />Well Destruction ❑ <br />Well Diameter Sealing Material (top 501 <br />Depth Filler Material (Below 501 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br />available within 200 feet.► <br />Installation will serve: <br />Residence _ Commercial _ Other <br />Number of living units: <br />Number of bedrooms <br />Character of soil to a depth <br />of 3 feet: Water table depth <br />SEPTIC TANK <br />❑ Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. <br />❑ Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE <br />❑ No. & Length of lines Total length/size <br />FILTER BED . <br />❑ Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS <br />I I Depth Size Number <br />SUMPS <br />Ll Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS <br />❑ <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: "1 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 />The applicant mut call for all requir d inspections. Complete drawing on r verse side. _ <br />Sig �... Title: Ott¢ Q Date: <br />POR DEPARTMENT USE ONLY <br />Application Accepted by Date Area 01, <br />Pit or Grout Inspection by Date Final Inspection by Date <br />Additional Comments: ~Q-5�c�?�6' <br />❑ Silk 466-6761 ❑ Lodi 369-3 1 ❑ enteca 823-7104 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E <br />+ EH 13-21 (REV. ti H5) <br />EH 14-29 <br />❑ Tracy 835-638 ;W1oma <br />Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Z�`� <br />FEE INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CASH <br />RECEIVED BY DATE PERMIT NO. <br />E <br />