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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> i PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> I , ; (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.,1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Lot Size �PM <br /> Job Address <br /> Phone <br /> Owner's Name it, Address <br /> ` 7 Phone��9`S f01 <br /> Contract _,- <br /> Address C'/ License N v <br /> TYPE OF WELL/PUMP: NEW WELL❑ �_ WELL REPLACEMENT © DESTRUCTION LJ 1 �. <br /> EJ <br /> PUMP INSTALLATION 71tix SYSTEM REPAIR ❑ OTHER <br /> ! pISPOSAL FLD. PROP. LINE <br /> f _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE'WELL' OTHER WELL PITS/SUMPS =; <br /> INTENDED USE "TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> Dia. of Well Casing <br /> El Industrial Ll Open Bottom ❑ Manteca Dia. of Well-Excavation f <br /> ❑ Domestic/Private 61Gravel Pack ❑ Tracy Type of Casing � <br /> Specifications <br /> {"1 Public a l�tl�,,Other <br /> F1 Delta Depth of Grout Seal Type of Grout — <br /> I I Irrigation - _Approx. Depth i I Eastern Surface Seal Installed by _ <br /> I Repair Work Done O Type of Pump H.P. State Work Done <br /> r " <br /> Sealing Material Itop 50'1 <br /> Well Destruction ❑ Well Diameter g <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALL TION Rf IWR/ADDITION l 1 DESTRUCTION-i `aNailab etlw hin 200 1system e`ii� ed if public sewer is <br /> r +°'°' V <br /> Installation will serve: Reiidence, Commercial— ther / y <br /> Number of living units: Number of b rooms f <br /> N. <br /> Character of soil to a depth of 3 feel: 6110 '.Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments f <br /> PKG. TREATMENT PL ❑ Methodof Dial <br /> ,. <br /> Distance to nearest: Well+ Foundation-= Proprty Line ...— / <br /> —Notal-IengtFi/siz`e <br /> LEACHING LINE o. & Length of lines. . ! ��//�/� <br /> FILTER BED ❑h Distance to nearest' y Well Foufldabon ..`— Property Line10 <br /> SEEPAGE-P17S; Depth Size <br /> v .(' <br /> Vum or <br /> SUMPS Distance to nearest: Well Foundations Property tine <br /> DISPOSAL PONDS ©h <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin 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: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manneras to become subject to workman's compensation laws of California." Contracto'r's hiring or sub-contracting signature <br /> certifies the following: 111 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 /> i <br /> The applicant mu II for,all reuire ins ctions. Complete drawingon reverse side <br /> P <br /> ' Signed X Title: ,L 1 Date• <br /> FQR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by // <br /> ` <br /> or Grout Inspection•by' a e Final lnspectioriby ate_"Tw <br /> Additional Comments: <br /> ElStk 4666781 ❑jLodi 369-3621 0- _7104_ <br /> CracyL—FW-6385 <br /> s ,,.Applicant.- Return.all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk.,CA 95201 <br /> ill - - '- • e_-.-„�.d-�^""�_ <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 0 r <br /> r.EH 13-24(REV.U"5) <br /> } EH 14-26 ! <br /> .i f <br />