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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> l Telephone (209) 466-6781 A, <br /> PERMIT EXPIH rl" EAR FROM •DATE ISSUED <br /> -A, .r• ' ,.1, (Complete in Triplicate) � <br /> all the work herein <br /> tion is <br /> Application is hereby made to the San Joolaq ui ordinalnce No.District Health 549 for sewage or permit <br /> 18&2 for well/dpump and the Rules and Regulations of he Santo Joaquin , <br /> made in compliance with San Joaquin County I i <br /> a <br /> Local Health District. " i } e ,, <br /> Alf /4" City Lot Size PM <br /> Job Address // ,% .r•7 �f�// <br /> Phone <br /> ddressTS/ <br /> Owner's Name <br /> License No. <br /> Phone COQ ✓ <br /> Contractor's Name DESTRUCTION 11TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ PROP• LINE <br /> SEWER LINES DISPOSAL FLD. Q� <br /> DISTANCE TO NEAREST: SEPTIC TANK, "I <br /> FOUNDATIONI�� AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Industrial C3 open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Type of Casing <br /> ❑ Domestic/Private i ❑ Gravel Pack a ❑ Tracy •�_ Depth of Grout Seal Type cf Grout <br /> ❑ Public ❑ Other L ❑ Delta <br /> ❑ Irrigation f _--Approx. Depth ❑ Eastern Surface Seal Installed by <br /> H.P. <br /> `:.` State Work Done <br /> Repair Work Done ❑ Type of Pump Sealing Material {top 50'} <br /> Well Destruction to Well Diameter <br /> Depth Filler Material (Below 50') <br />' available within 200 feet.! ' <br /> TYPE OF SEPTIC WORK: NEW INSTAI ATION REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septi system permitted if public sewer is <br /> q . <br /> installation will server Residence commercial— Other�— <br /> r <br /> Number of living units Number of Brooms �.� <br /> Water table depth <br /> Character of soil to a depth of 3 feet: , Capacity No. Compartments <br /> SEPTIC TANK B Type/mfg: Method of Disposal <br /> s 7 <br /> PKG. TREATMENT PLT: est: Well ! oun — Property' Lirte <br /> + Distance to-near <br /> r ". :,-- Q I Total length/size �,r1 <br /> LEACHING LINE C9�No. & Length of lines. f ,� Property Line <br /> Foundation L-�� <br /> FILTER BED :1;i,"Distance to nearest: Well n <br /> z <br /> SEEPAGE PITS pth -Size--'m-1 <br /> '�'� Number <br /> moi'Foundation Property Line <br /> i SUMPS0_'Distance to nearest > Well <br /> DISPOSAL PONDS ❑ <br /> k I hereby certify that 1~F1ave prepared this application and"tYiat 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 /> iwork t -contracting <br /> signature <br /> such a subject to <br /> asht �s tion s hiring of California."Contractor's <br /> emplo any person <br /> nn m tiissuedl shall employ personssubjctwokmans ompensa <br /> certifies the <br /> lcertify tha n the ofhe fowhcp <br /> tion laws of California."-- <br /> The applicant must call r all required inspections. Complete drawing on reverse side. G2�� <br /> Date: <br /> Signed 4 <br /> { Title:� � - •« <br /> FOR DEPARTMENT USE ONLY <br /> A Date Area — <br /> Application Accepted by t L- <br /> '- g Final Inspection by Date <br /> Pit or Grout Inspection by a V Date — <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi -369-3621 ❑ Manteca 823 7104 ❑ Tracy 83`x ` Stk., CA 95201 <br /> Applicant Return all copies to: Environmental Health PerrnitlServices 1601 E. Hazelton Ave., P;O. Box 2009, <br /> i <br /> CK RECEIVED BY DATE PERMIT-NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> . + EH 13-24(REV.101931 <br /> EH 14-25 <br />