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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ! <br /> " 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I <br /> (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. J r <br /> Job Address xo 0 �� ---�— <br /> Lot Size pM <br /> ddiess . <br /> Owner's Name Phone <br /> r � <br /> {�, � Q k- <br /> Contractor's Name - V V' v Li se No. Phone <br /> TYPE OF WELL/PUMP: NEW WELt ❑ WELL RE LA EMENT` DESTRUCTION ❑ <br /> a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> M--t .c _..� - <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> F . <br /> OUNDATION <br /> A _ <br /> AGRICULTURE WELL , OTHER WELL PITS/SUMPS <br /> INTENDED USE r TYPE OF WELL PROBLEM AREA <br /> CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i <br /> ❑ Domestic/Private ❑ Gravel Packl' ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other 11 Delta Depth of Grout Seal <br /> 1 p Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by t + <br /> Repair Work Done ❑ Type of Pump H.P• ' ; <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 i <br /> Depth Filler Material (Below 501) ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> ! &ailable within 200 feet.) <br /> Installation will serve: Residence Commercial ',. Other+ ti+J ` 0 <br /> Number of living units: - Number of bedrooms 1 Of <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ r Method of Disposal y' <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� __-Foundations Property Line <br /> I <br /> SEEPAGE PITS ' - Depth Size Nu ber <br /> SUMPS t ' Distance tohearest: Well I 1 Property Line <br /> DISPOSAL PONDS ❑ li .._ <br /> r ' Foundation. rE <br /> . I <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. ' I a i <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 1 <br /> employ any person In such manner as to become subject to workman's compensation laws of California."Contractoes 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 laws of California." <br /> The applicants t call for all r inspe. ions. omplete drawing on revs! ide. !: <br /> Signed Title: • Date: <br /> FOR DEPARTMENT U ONLY t, a <br /> Application Accepted.by Date Area ( + <br /> r <br /> Pit or Grout Inspection by Date Final Inspection byW—' �� 'Date <br /> Additional Comments: I ' <br /> t <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE! PERMIT'NO. <br /> INFO CASH <br /> EN 13-24(REV.101831 —Lis, �O <br /> EH 14-28 f 1ST^` Ly –�i`7�C f <br />