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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) 4661-6781 <br /> { PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> • (Complete in Triplicate) ti <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. <br /> Job Address <br /> Qp City d�Lot Size �PM <br /> Owner's Name _ lr�d/�QRI Address o Q / j��N �+�^ <br /> S <br /> ' Phoned i' -Z a/d <br /> Contractor's Name <br /> License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ Phone J Y <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION �" SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK (� OTHER 0 <br /> SEWER LINES ------7_ DISPOSAL FLD.Y PROP. LINE <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS ! <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom El Manteca <br /> Dia. of Well Excavation Dia. of Well Casing <br /> TP EI❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Other 11 Delta Depth of Grout Seal <br /> ❑ Irrigation Approx. Dept stern Type of Grout <br /> Repair Work Done ❑ Type of Pump:I Su Seal Installed by <br /> H.P. ff <br /> Well Destruction ❑ Well Diameter i State Work Done o <br /> Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: ResidenceCommercial_ Other available within 200 feet.) <br /> Number of living units: Numbericf bedrooms <br /> Character of soil to a depth of 3 feet: j <br /> SEPTIC TANK ❑ Type/Mfg ! Water table depth <br /> PKG. TREATMENT PLT. ❑ , Capacity No. Compartments <br /> Distance to nearest:' Well Method of Disposal <br /> Foundation_�,�_ Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BEDTotal length/size <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth ` <br /> - Size """ Number <br /> SUMPS El Distance to nearest: Well <br /> DISPOSAL PONDS ❑ Foundation Property Line 3 <br /> S <br /> 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: # <br /> employ an g: '"I certify that in the performance of the work for which this permit is issued, I shall not <br /> p Y y 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 <br /> P work for which this permit is issued,I shall em loY persons subject to workman's compensa- <br /> tion laws of California." <br /> I <br /> The applicant"191 1 f Ireq ' d inspe ions. mplete drawing on rev side. <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by f ,�f d <br /> i,.� A?¢f .4«0 %1 � <br /> DatePit or Grout Inspection bya Date ""' .--�� fj�nal Inspection by DateAdditional Comments: AJ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 '`� _ <br /> Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental H Ith Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk.,JQA, ;J .1 <br /> .�ldl3 ` 1l z° I <br /> FEEEn!E CK f <br /> INFOAMOUNT REMITTED CASH RECEIVED BY DATE I <br /> PERMIT"NO. <br />+EN 13-24(REV. 10/83) ! <br /> EH 14-28 r�l <br /> 5.- T <br />