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�} APPLICATION FOR PERMIT <br /> C`! o"` 0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 <br /> a <br /> N,3'9 #CC I-* <br /> Job Address 3oM '4"V* QZ1 S/ YaA ryo.y*1Vr,, cit 4 e- <br /> tltl Y , Lot Size PM <br /> Owner's Name 40—to".6 Address _ .>�3� AC CIA <br /> Phone <br /> Contractor I-11r, Address ln.0, #e,,r 110 161"C` 49 <br /> License No. yyy�f Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,❑ DESTRUCTION El <br /> INSTALLATION F-1SYSTEMREPAIR ❑ OTHER ❑ <br /> DISTANC p NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> » FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL , PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> -Dia. of Well Casing <br /> ;❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> CI}Public ❑ Other ❑ Delta Depth of Grout Seal <br /> Type of Grout t <br /> ❑hrrigation _--Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Re0air Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 21 DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence� Commercial_ Other available within 200 feet.) <br /> Number of living units: / Number of bedrooms 1� <br /> Character of soil to a depth of 3 feet: L"" Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments y <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED V Distance to nearest: Well p & Foundation /.f <br /> Property Line /S` <���>(b/x <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ PropertyLine <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. <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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: f'••/�-y� <br /> Date: <br /> FOR DEP RTMENT SE ONLY <br /> Application Accepted by Date <br /> U Area <br /> Pit or Grout Inspection by Date Final Inspection by S^ <br /> Date__/� � <br /> Additional Comments: /- <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-6385 <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 <br /> INFO ASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13.24(REV.line) r Q Q'A <br /> EH 14-28 / /f o <br />