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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) 466-6781 <br /> �I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i <br /> Application is heteby 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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. I. <br /> IIS , <br /> D S�'D O � � City 1 Lot Size PM <br /> Job Addres <br /> / - Address a�SCJ 0 Phone <br /> Owner's Name I <br /> r6 � . d.� 73 i'hone!e 96 <br /> Contractor Address r License N <br /> TYPE OF WELL/PUMP:: ,lp NEW WELL ❑ . WELL REPLACEMENT F1 DESTRUCTION DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP:LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1�rindustrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation <br /> Dia. of Well Casing <br /> . <br /> Type of Casing Specifications' <br /> ❑ Domestic/Private 171 Gravel Pack ❑ Tracy`- YP g <br /> l'1 Public ❑ Other Cl Delta r'' I, Depth of Grout Seal Type of Grout <br /> " A rox. Du h I ! Eastern ` Surface Seul Installed by `\V\ <br /> I 1 trrigauon —� Pp <br /> a Repair Work Done C� Type of Pump �""r'`�`R H-P: State Work Done <br /> c� Well Destruction ❑ Well Diameter Sealing Material Itop 501 ` <br /> Depth ; <br /> Filler Material IBelow 50'1 <br /> k REPAIR/ADDITION l ) DESTRUCTION I I INo septic system permitted if public sewer is <br /> TYPE OF SEPTIC'WORK: NEW INSTALLATION 11 <br /> available within 200 feet.-) "_ <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: ri Number of bedrooms <br /> f Character ofsoil to a depth of 3 feetWater table depth <br /> feet: <br /> SEPTIC TANK L ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT;PLT. El * Method of Disposal <br /> li <br /> Distance to nearest: Wel! Foundation Pro0erty.Line <br /> LEACHING LINE �D 'L1No. & Length of tines 1 Total length/size <br /> FILTER BED h ❑ I�Distance to nearest: Well Foundation Property Line <br /> j SEEPAGE PITS„ 11 1IDepth `'' ' Size <br /> i Number <br /> SUMPS Ll IDistance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ II :" <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, an } <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, 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 peisons.subject to workman's compensa- <br /> tion laws of California." <br /> i The applicant ust c II for all requ' d inspections.'Complete drawing on reverse side. <br /> Dare: 9 <br /> vrr"�/ ;1t'4Tfitle• YL� ' - <br /> i Signed X <br /> II FOR DEPARTMENT USE ONLY.. <br /> y Date Area <br /> ! Application Accepted by - q <br /> j <br /> Pit or Grout Inspection by Date al"Inspection-by <br /> at <br /> 7 �al�n lQass — lI��f tss..� . <br /> Additional Comments: a 1; f <br /> — :=- .2 w <br /> ❑ Stk 466-6781 ❑ Lodi 369- 1��` ❑1 Manteca 823 7104 `Q'Tracy 1335 <br /> Permit/Services 1601 E.'Hazelton Ave.,"P.O. Box 2009, Stk., CA 95201 <br /> Applicant - Return all copies;to: Environmental Health <br /> til _ r <br /> FEE AMOUNT DUE AMOUNT REMITTED "CASH <br /> BY DATE PERMIT`NO. <br /> INFO <br /> k ♦.EH 13-24 tREV-I/H 51 � J _ h ~�Z _ <br /> EH 14-2e <br />