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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6783 a `w <br /> { PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIROtVEN{AL HEALTH <br /> (Complete in Triplicate) FER`AiT/SERVICES <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 /> . f4 <br /> Job Address City s Lot Size PM <br /> .Owner's Name Address3 Phone .3;K- 4 04 <br /> ContractoAddress P/ L 45-7 1 _Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WE REPLACEMEN ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION YSTEM 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-WEL! PROBLEM AREA CONSTRUCTION SPECIFICATIONS �..,:Y .. <br /> ❑ Industrial ❑ Open Bottom �❑ Manteca Dia. of Well Excavation ri-Dia.of Well Casing <br /> ADomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal T ' Q <br /> ype of Grout <br /> I Irrigation —Approx. Dept 1 1 Eastern Surface Seal Installed by i <br /> Repair Work Done 1 Type of Pump H.P. -2 State Work Done ' V <br /> Well Destruction ❑ Well Diameter; $ s <br /> _ _ � Sealing Material (top 50'j <br /> Depth 1-301 <br /> Filler Material (Below 501 <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1:] REPAIR/ADDITION I.I DESTRUCTION I )-(No septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence_f Commercial__ Other ti <br /> Number of living units: Number of bedrooms . <br /> Character of soil to a depth of 3 feet: ;F <br /> Water table depth' <br /> q <br /> SEPTIC TANK 'El Type/Mfg 4 Capacity No. Compartments <br /> PKG..TREATMENT PLT. ❑ t Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r <br /> SEEPAGE PITS 1 I Depth Size Number t c <br /> SUMPS L1 Distance to'nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <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. ; f <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 Aperso uch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contractingcertifies certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's Comtion lawThe appa f r all. it d inspections. Complete drawing on reverse si <br /> Signed 10FTitle: ^' Date: ! <br /> -/�° r�_ FOR DEPARTMENT SE ONLY <br /> Application Accepted by `�^'"�' Qi 7` <br /> -• Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments:, d <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca/823-7104 ❑ Tracy 835-6385 1 <br /> Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2000, Stk., CA 95201 <br /> { <br /> FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT'No. <br /> + EH 13-24 IREV.t/x 51 _ <br />