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bS APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �. 1 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209? 466-6781s � .3 <br /> PERMIT EXPIRES 1YEAR FROM DATE ISSUED -q4 r; _ <br /> won � 4. ., ,.,(Complete in Triplicate) 6-tO 06 ' <br /> �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 Or_dinanc N 549 for sewage or No- 1862 for well/pump and the.Rules and Regulations of the San Joaquin <br /> Local Health District. .C3t j , q <br /> City�. <br /> Lot Size <br /> Job Address <br /> L : r <br /> ,;":.. <br /> Phone <br /> Owner's Name <br /> res <br /> Contractor dress cense No. � Phorie_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <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 /> 4. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial O Open Bottom. ❑ Manteca Dia. of Well Excavation Dia: of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Type of,Grout <br /> ❑ Public L1 Other ❑ Delta Depth of Grout Seal, h, y <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done r . <br /> Well Destruction Q Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 y <br /> TYPE OF SEPTIC WORK: NEW iNSTALLATIONA REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> "available within 200 feet.) <br /> r <br /> Installation will serve: Residence Commercial_ Other t, <br /> Number of living units:—/ Number of bedr ms TM ! i <br /> Character,of soil to a depth of 3 feet: : <br /> Water table depth D <br /> SEPTIC TANK ❑ Type/Mfg t Capacity 00 No. Compartments <br /> z PG <br /> _K ,TREATMENT PLT. ❑ / J / Method of �sposal <br /> Distance to nearest: Well [ t/ Foundation� Property Line Y ` <br /> LEACHING LINE µx ^No. & Length of lines Total length/size a � ' <br /> r ,ky D Prop <br /> erty tine <br /> =' FILTER BED ❑_ ..Distance to nearest: Well D� Foundation <br /> P <br /> L p <br /> � n y <br /> SEEPAGE PITS Depth t E Size_g� Number C <br /> I r <br /> SUMPS,. <br /> O _ Distance to nearest: 4�Well Foundation .___ rt'-Line �� r <br /> DISPOSAL PONDS ❑ ' <br /> Thereby 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 /> 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 /> r 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 /> Theapplicant st c r qu ji4s ctions. Compl to awing r side. <br /> Title: — Date: <br /> Signed X A-- — <br /> R DEPARTMEM SE ONLY <br /> Application Accepted by " Date', J a <br /> E Pit or Grout Inspection by Date/1 a! inal f pection by Date_Apd <br /> itional Comments: <br /> Stk 466-6781 ❑ Lodi 369=3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Ap icant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9'x201 <br /> f , <br /> : FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ` DATE PERMIT'NO. <br /> § INFO <br /> I ss' �s- <br /> + EH 13-24(REV.i/a 51 �� ! Ir- !yam <br /> r — <br /> EH 1428 <br />