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.. APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT j <br /> :1'601 E..HAZEL T O:N.=AVE:, STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> •pit> _r �.rz .;. u .- . - . . (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...,i�, *s ."G7~ : 7 �•,: t <br /> Job Address <br /> City Lot Size PM_ <br /> 47 jr <br /> Owner's Name R �72 <br /> Address Phone <br /> Contractor's NamNo.A, y� - Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 1-1 <br /> PUMP INSTALLATION 42/ SYSTEM REPAIR ,C] OTHER ❑ 1 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK d SEWER LINES V_ DISPOSAL FLD. I PROP. LINE _0 <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL od� [ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial -I3 Open Bottom ❑ Manteca Dia. of Well Excava 'o O Dia. of Well Casing <br /> EIbomestic/Private p'tiravel Pack ❑ Tracy Type of Casing_ Cl ASpecifications <br /> (7 Public' ❑ Other El Delta Depth of Grout Seal s�v` i Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by ' <br /> Repair Work Done ❑ Type of Pump H.P., State Work Done II <br /> Well Destruction 17 Well Diameter _7 C'., At.NSealing Material (top 50'1 <br /> Depth --Filier_Material {i3eiow,_50D_ <br /> TYPE OFSEPTICWORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence — Commercial Other <br /> Number of living units: Number of bedrooms I ' <br /> Character of soil to a depth of 3 feet:- r Water itable depth ` <br /> F SEPTIC TANK 'ElType/Mfg Capacity No. Clmpartments <br /> PKG. TREATMENT PLT. ❑ {. Method of Disposal <br /> 'Distanbe to.nearest: well `='Foundation Property Line <br /> .x <br /> LEACHING LINE ❑ �No &°Length of lines `' N ru Total length/size <br />' 1 •- j .F _u_ndation Property Line <br /> FILTER BED 1 � ❑ •Dis#ante to nearest: � Well i <br /> II <br /> SEEPAGE PITS n Depth & .31 Size I Number <br /> I <br /> SUMPS }❑ Distance to nearest ---Well 7�--___Foundation Property Line <br /> DISP SAL PONDS 1-2 <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, a <br /> rules ani( 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 permit is issued,I shall employ persons subject to workman's compensa- <br /> tion lalnis'of California." ' <br /> The applicant pivst call for all required 1 spections. Complete drawing on reverse side. j <br /> Signed X �'Y1Lte: Date: <br /> r - FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �� I Area <br /> 13 <br /> Gj/ date <br /> .Pit or Grout Inspection by �atI I�� F'nal,lnspecti n by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Ment 823-71 ❑ Tracy 83545305 <br /> Applicant-Return all copies to: Environmental aith P rmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT'REMITTED CK RECEIVEf3'BY DATE PERMWNO.- <br /> INFO CASH <br /> +EH.13-24 Mtv.10/83! <br /> Eli <br />