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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> t Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t and/or install the work herein described. This application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construc <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welilpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Ar <br /> 44 <br /> .._ City Lot Size PM <br /> Job Address „ <br /> Owner's Name <br /> OV O /6 Address Phone <br /> License No <br /> d�D Phone4/7 <br /> Address <br /> F Contra WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER 13 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br />' <br /> DISPOSAL LLD. PROP. LINE <br /> DISTANCE TO NEAREST:,SEPTIC.TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> v <br /> INTENDED USE TYPE OFWELLPROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial C Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ' Type of Casing Specifications . <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> M Public Other F1 Delta Depth of Grout Seal Yp ­ <br /> 1 <br /> ! <br /> 1 1 Irrigation —._Appr�. Depth I I Eastern Surface Seal installed by <br /> Type of PH.P. State Work Done _ <br /> k Repair Work Done LlTyp Pump <br /> Weil Destruction ❑ Well Diameter ' Sealing Material flop 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INS'ALLATION REPAIR/ADDITION l I DESTRUCTION i I (No septic <br /> lable system <br /> m rented if public sewer is f <br /> Installation will serve: Resifdence Commercial Other <br /> Number of living units: ___L' Number of bedrooms T <br /> Water table depth <br /> Character of soil to a depth of 3"feet: <br /> t Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> y� Method of Disposal <br /> PKG. TREATMENT-PLT._❑ a + �{ <br /> F Distance to nearest::,Well 6—0 ' Foundation Property Line I <br /> LEACHING LINE X1 ,No. & Length of lines.» - ' f a Total length/size SIC <br /> l� <br /> FILTER BED 11 Distance to nearest: Well Foundation Property tine <br /> 41a <br /> Jr <br /> SEEPAGE PITS I i Depth° Size Number a/ f <br /> SUMPS Distance to nearest: <br /> Well Foundation Property Line ` "� d <br /> DISPOSAL PONDS ❑I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, st <br /> rules and regulations of the San Joaquin Local Health District. <br /> l Home owner or licensed agent's signature certifies the following: 111 certify that in the performance of the work for which this permit is issued, I shai4 not R <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 P <br /> certifies the following:111 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 inspections. Complete drawing on verse side. k r <br /> Title: Date:" <br /> Signed <br /> t FOR DEPARTMENT USE ONLY <br /> ^�Date r` Area <br /> Application Acce d by � - <br /> Pit or Grout Inspection <br /> Date `� Final Inspection by e <br /> Additional Comments: <br /> ' L) Stk 4&6-6781 ❑ 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, Sika, CA 95201 <br /> FEECK RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> AMOUNTr DUE AMOUNT REMITTED CASH <br /> +.EH 13-24 1 REV.1/x 51 <br /> EH 14-26 <br />