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r' <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE,I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 - <br /> .,PERMIT EXPIRES .1 YEAR FROM DATE ISSUED r <br /> 4 {Complete..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 gompliance 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 /> _ Citl>�C Lot Size PM <br /> I Job Address rr y �- <br /> t <br /> Owner's Name j �. r4Ji" Address Phone <br /> �1nr) �-� �- Phone <br /> Contractor's Name F�'� cense No. <br /> TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTAL LA7 ON ❑ SYSTEM REPAIR ❑ OTHER ❑ �/ <br /> DISTANCE TO NEAREST: SEPTIC TANK; SEWER LINES QD DISPOSAL FL POP. LINE '� Q <br /> SN 4 t - AGRICULTURE WELL I, OTHER WELL �.- i'ITS/SUMPS <br /> J FOUNDATIO LL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y" ft <br /> ❑ Industrial L1 Open Bottom Ll Manteca Dia. of Well Excavat <br /> io <br /> n <br /> Dia.*of Well Casing v ,� <br /> t. Gravel Pack ❑ Tracy Type of Casing - uc �' Specifications <br /> L Domestic/Private K <br /> Depth of Grout Seal Type of Grout <br /> ❑ Public ❑ Other El Delta <br /> '2f Irrigation ---A . Depth ❑ Eastern Surface Seal Installed by �r <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction Elc Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material (Below 501 [n <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑, REPAIR/ADDITION El DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> , available within 200 feet.) - <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units:, Number of bedrooms <br /> Character of soil to a depth of,3 feet:l Water table depth <br /> SEPTIC TANK I❑ Type/Mfg Capacity No. Compartments i <br /> Method of Disposal <br /> PKG, TREATMENT PLT:J❑ ^' <br /> Distance to nearest: Well Foundation Property Line <br /> ' Total length/size <br /> LEACHING LINE ❑ .No. & Length of lines <br /> ~� FILTER BED - " 1 Distance to nearest: Well Foundation Property Line <br /> r +; <br /> SEEPAGE PITS :❑ Depth �%Size Number <br /> SUMPS r0. Distante to-nearest: ,Well' Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Joaquin Local Health District:".. - <br /> i Home owner or licensed-agent's signature 6ertif4s'-the following: "I certify that in the performance of the work for which this permit is issued, I shei 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 sign ture <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 compnsa <br /> tion laws of California. t <br /> The applicantpuat-egVbr all required inspect ns. Complete d ing on r verse side. <br /> 77 <br /> Signed )C_jti'r Title: m Date: l <br /> FOR DEPARTMENT USE ONLY �r- <br /> Date —U�- i <br /> O� _ Area <br /> Application Accepted by. �� 3 <br /> Pit rout spection by ate �`6final Inspection by Date j <br /> c1 <br /> SSW A <br /> Additional Comments: � <br /> ❑ Stk 466-6781 ❑ Manteca 823-7104- ❑ 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 /> rc� AMOUNT DUES` " �IJNT REMITTED�6K- "" RECEIVED BY <br /> DATE T I'ERMIY'N0. <br /> ` 1NF0 CASH r <br /> + EH 13-2a <br /> EH 14-26 la-ev.ioraa> /lqi v.5B5 _�7 <br /> - <br />