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APPLICATION FOR PERMIT <br /> ,l. <br /> E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �3 6 <br /> 'Al"M <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 0 CI 1 1 <br /> Telephone (209) 466-6781 _NTAL HEALT11 , <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED _;'`'.'2_;'`'.'2- _ -i <br /> (Complete in Triplicate) r <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. it <br /> Job Address _,�2D�-1 S'a City at!�,- Lot Size PM <br /> Owner's Name Address Phone <br /> ii <br /> 7:? <br /> _;10 <br /> Contractor -Address. %s t2 No. 49 Phone <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT 0 DESTRUCTION C1 <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER LJ <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 /> 0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> *omestic/Private 0 Gravel Pack LJ Tracy Type of Casing Specifications <br /> M Public f7 Other H Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.:Approx. Depth I I Eastern t Surface Seal Installed by <br /> Repair Work Done Type of Pump ed H.P. State Work Done <br /> Well Destruction Cl Well Diameter Sealing Material ito'p SOT N <br /> Depth <br /> Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADDITION I I DESTRUCTION I I (No <br /> septic system permitted if Public sewer is <br /> available within 200 feet.I, <br /> Installation will serve: Residence— Commercial ._ Other <br /> Number of living units: Number of bedrooms <br /> Character'6f soil to a depth of 3feet: Water table depth <br /> , <br /> SEPTIC TANK 0 Type/Mfg 6apacity No. Compartments <br /> PKG. TREATMENT PLT, 0 --py 4 <br /> Method of Disposal <br /> Distance to nearest: t Well Foundation Property Line" <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED IJ Distance to nearest: Well Foundation— Property Line <br /> SEEPAGE PITS C I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation— Property Line <br /> DISPOSAL PONDS 0 <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 zJoaquin 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 call I all <br /> reqt�ife ins actions. Complete drawing on reverse side. <br /> _ <br /> Signed XTitle: P, Date- _A,C_�f <br /> II <br /> r — <br /> FOR DF^RTMENT USE ONLY <br /> Application Accepted by DateZ/R-Nt,, Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Ll Stk 466-6781 0 Lodi :369-3621 0 Manteca 1123-71104 El Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# <br /> INFO RECEIVED BY DATE <br /> CASH PERMIT'NO. <br /> -EH 3-241REV.1/85) <br /> EH 14-26 LA_S� <br /> -9 <br />