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APPLICATION FOR PERMIT I <br /> 0' , 4 . .4 _ <br /> 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 /> Com I <br /> { p ete 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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address } fS' <br /> City Lot Size PM <br /> -Owner's Name Address' – - Phone <br /> Contractor !' Address License No. � Phone " <br /> TYPE OF WELL/P P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER .❑ <br /> DISTANCE TO NEAREST: SEPTIC 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack'.. ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other NN,,,❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑-Eastern Surface Seal Installed by <br /> c <br /> Repair Work Done ❑ Type of Pump '�`''�H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> e Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑': REPAIR/ADDITION A DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence. rommercialr" Other ' <br /> Number of living units: Number of drooms ` <br /> Character of soil to a depth of 3 feet: �^" 'A'e it, Water table depth C <br /> SEPTIC TANK 42,f Type/Mfg - mt, 1. Capacity '49No. Compartments <br /> PKG. TREATMENT PLT. ❑ " Method of Disposal <br /> 0.�' <br /> ' Distance to nearest: Well Founda4tion Property Line <br /> LEACHING LINE ; <br /> . +' �" ❑' No. &.Length of lines Total length/size <br /> �:w t <br /> FILTER BED' r ❑,_. Distance to-nearest:?k� Well ) Foundation Property Line <br /> SEEPAGE PITS ❑ 'Depth ' Size Number <br /> SUMPS ?r{* i , Distance to nearest: ,.' Well Foundation Property Line <br /> z_- -� , <br /> DISPOSAL-PONDS ED t �.t. j <br /> hereby certify that F have,prepaied this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulationslof 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." )"t, <br /> The applicant must call for fired inspections. Complete,drawing on re erse side. <br /> Signed X Titlet "'. Date: <br /> i FOR DEPARTMENT USE ONLY <br /> �(r d :., N ► <br /> Application.Accepted by C ' Dae , Area c <br /> `w--Pit or Grout Inspection by ' ate, —Final-I p o y Date <br /> Z,XAdditional,Cori r;bnts h <br /> O Stl 4664781" ❑ Lobi 369421 ❑ Manteca'823:7164 __P Tracy 835 6385 ' <br /> Applicant- Retur'n all copies to: Environmental Health Per mit/Services 1601 E. Hazelton Ave', P:0. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO .AMOUNT DUE AMOUNT REMITTED . CASH, RECEIVED_.BYAy.',' ,Cr DATE. PERMIT•NO. 1111 <br /> + EH 13-24(REV..'1195) <br /> EH 14-28 <br />