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-14 <br />APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZE T ON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(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 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. 1 Jam/ -5-9"--" <br />I lot.` ( Lot Size <br />Job Addr00, <br />Bss <br />Owner's Name(1I--[- Address f _ <br />�( r Phone <br />ContractorI <br />Address icense No. <br />I q&C <br />TYPE OF WELL/POMP: NEW WELL G WELL REPLACEMENT ❑ DESTRUCTION J <br />` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br />DISTANCE -TO NEAREST: SEPTIC TANK SEWER HNES 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 C Manteca Dia. of Weli Excavation Dia. of Well Casing <br />I <br />Ci Domestic/ Private G Gravel Pack U Tracy Type of Casing _- Specifications <br />M Public Li Other 171 Delta Depth of Grout Seal Type of Grout <br />I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by - ----- . <br />Repair Work Done U Type of Pump H.P. State Work Done <br />Well Destruction LJ Well Diameter Sealing Material (top 50') - --- <br />, r <br />Depth Filler Material (Below 50") --- - -- -- <br />TYPE OF SEPTIC WORK: NEW INSTALLATION IV REPAIR/ADDITION 1 1• DESTRUCTION I Mo septic system permitted if public sewer is <br />available within 200 feet.) <br />t Installation will serve: Residence -L Commercial Other J ;t <br />Number of living units: --L— Number of bedrooms <br />Character of soil to a depth of 3 deet_ Water able depth <br />-�. �! ._ ..... ' <br />No- Compartments <br />- <br />SEPTIC TANK ❑ Type/Mfg GHPactty <br />' r� <br />s �PKG. TREATMENT PLT. L f Method of Disposal � { <br />Distance to nearest: Well 10 t- Foundation � Property Line <br />LEACHING LINE No. & Length of lines Total length/size _ - :_------- — <br />I Q i <br />I FILTER BED t Distance to nearest: Well Foundation_ Property Line _ <br />I <br />SEEPAGE PITS I I Depth X r� X Size � Number <br />'UMP C: Distance to nearest: Well 6(2_+ Foundation <br />Property Line— <br />DISPOSAL PONDS Fj <br />I hereby certify that I have prepared this application and that the work will be dorsi 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 ih8 ct to workman's compensatio <br />following: '"I certify that in the performance of the work for which this permit is issued, I shalt not <br />tom" to become subje'n laws of California.'" Contractor's hiring or sub -contracting signature <br />employ any parson In such manner n <br />+f? certifies the following: " i certify that in the perforrnance of the work for which this permit is iss rail, I shall employ persons subject to workman's Compen5a <br />1 tion laws of California." <br />t The applican trst II for ail req ed inspections. Complete drawing an/ri rse side. <br />Signed X Title:lam' ` t�� Pte✓ __ __ Date: _ZC <br />j FOR DEPARTMENT USE ONLY <br />1 DateJ��G7 - A ea Z <br />Application Accepted by <br />�+�c� i- <br />� Final Inspection by Da tf <br />�it grout In ction by <br />Additional Comments: <br />❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 L1 Tracy 835-6385 <br />Applicant - Return all copies to: Environmental Health Permit/ Services 1501 E. Hazelton Ave., P.O. Box 2009, Stk, <br />FEE j;NT DUE AMOUNT REMITTED CASH <br />` INFO <br />EH 13-24 (REV.%K 51 <br />C <br />EH 14.2e <br />CA 95201 <br />BY DATE PERMIT NO. <br />03 <br />