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APPLICATION FOR PERMIT . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA ` <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> iComplete-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 /> r — _ <br /> Job Address ` � �. � 5�<�� R V> city <br /> G Lot Size PM <br /> Owner's Name L Address ! Z Phone <br /> Contractor__. Address License No. Phone <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ElSYSTEM REPAIR ❑ OTHER LIDISTANCE TO NEAREST:"SEPTIG TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 00,pen Bottom ❑ Manteca,, Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑.Tracy -Type ol,Casing Specifications <br /> r FI Public F1 Other .A,.I " r Delta ":.` Depth of^Grout Seal" Type of Grout--­ <br /> I <br /> rout _.. <br /> I I Irrigation App"roK. Depth l l Eastern ,,.-Surface Seal Installao by'% <br /> Repair Work Done ❑ Type of Pump, -H:P. State Work Done <br /> Well Destruction ❑ Well Diameter ` 1 •l Sealing Material (top 501 <br /> Depth Filler Material (Below 50, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION. REPAIR/ADDITION l 1,-DESTRUCTION I i INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> z "" <br /> Installation will serve: ResidenceCommercial' Other-, <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ey � !y."r I Water table depth <br /> SEPTIC TANK 0. Type/Mfg Capacity �a No. Compartments r <br /> PKG. TREATMENT PLT. ❑ // .rMethod of Disposal rV�) <br /> D stance to nearest: weir- ._ Foundation Property Line �� v I <br /> I CY <br /> LEACHING LINE. " No. & Length of lines `� Total length/size 17 <br /> FILTER BED © Distance to nearest: Well Foundation ff Property Line <br /> IF <br /> SEEPAGE PITS l I Depth iz6, Number <br /> 6 -SUMPS ❑ Distance to nearest: Well foundation Property Line a <br /> E DISPOSAL PONDS L. . <br /> 1 .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 fotlowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> t 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 call tor"Zrired inspections. Complete drawing on reverse side. <br /> Signed X < Title:_ Date: <br /> 1 •FOR DEPARTMENT USE ONLY ¢ / <br /> Application Accepted by ` Date o Area 2 l b <br /> Pit or Grout Inspection by ` Date Final Inspection by Date <br /> Additional Comments: <br /> t ❑ Stk 466-6781 ❑ Lodi. 369-3621 ❑ Manteca 823-7104 Cl 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�-- *^^ •- INFO"' AMOUNT-DUET .,.AMOUNT.REMITTED_ Y CASH"" "*'^""RECEIVED-BY------ —DATE•�.�.-•-",-- �PERMIR"NOS <br /> +.EH 13-24(REV,I/H 5) ­ 4-To--- <br /> - d IS—"'r 'PC/— 13'lCi <br />