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1 Ir <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA, <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IGP7g (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 d�es�cribad This application is <br /> made H 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. 71,44,; +` <br /> Jab Address TNO I I�/fAPk 7 r. <br /> City f G Lot Size PM <br /> Owner's Name � ^M� Address <br /> Phone <br /> Contractor's Name <br /> License No. f{ <br /> TYPE OF WELL/PUMP: NEW WELLPhone' <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATPON SYSTEM REPAIR-Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK // OTHER ❑ <br /> .. _ SEWER LINES 140 DISPOSAL FLD. PROP LINE <br /> FQUNDATION _/��_ AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> Dp <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� <br /> ❑ Industrial El.-Open Bottom ❑ Mantecai <br /> ❑ Domestic/Private ❑ Gravel Pack' Dia. of Well Excavation Dia. of Well Casing <br /> (Public ❑ Tracy Type of Casing <br /> I Other' ' C1 Delta Depth of Grout Seal Specifications <br /> Ll Irrigation �Ajiprox`Deptli"'�❑ Eastern Type of Grout I <br /> Repair Work Done❑ Type of Pump I Surface Seal Installed by <br /> t <br /> —� H.P. State Work Done <br /> Well Destruction 1) Well Diameter I <br /> �, Sealing Materia! (top 50'1 <br /> Depth Filler Material (Below 501) { <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ {NQ septic-------------- <br /> system permitted if public sewer is <br /> Installation will serve: Residence available within 200 feet.) <br /> Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: i <br /> SEPTIC TANK ❑ Type/Mfg Water table depth ' <br /> PKG. TREATMENT PLT. ❑ Capacity— No. Compartments <br /> nearest: �/s/ep Method of Disposal <br /> Distance to n ! ' <br /> I Foundation Property Line <br /> " LEACHING LINE <br /> ❑ No. & Length of lines <br /> FILTER BEDTotal length/size <br /> ❑ Distance to nearest: Well Foundation <br /> 1 a Property Line <br /> SEEPAGE PITS ❑ Depth I Size <br /> SUMPSNumber <br /> ❑ Dij <br /> stance to nearest: Well Foundation <br /> f DISPOSAL PONDS [D Foundation Line <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 /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which thi permit is issued, I shall not <br /> r employ any p rson in such manner as to become subject workman's compensation laws of California."COntfactbi's hiring or sub-contracting signature <br /> certifies the wing`:"I certify that in the performance o the work for which this <br /> tion laws of C ifornia." p� permit is issued,!shall employ persons subject to workman's compensa- <br /> The t call forre ed i <br /> pections. Co plate drawing on reverse side. <br /> Sig <br /> Title:_Cy <br /> _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �. <br /> Date d ` " �! - Area 7 <br /> Pit or Grout Inspection by Date r'B 7 - <br /> Final Inspection by Date <br /> Additional Comments: .� �' ►i '� <br /> i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ' ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 E <br /> FEE AMOUNT DUE � AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATEPERMIT N0 , <br /> �J . <br />+ EH 13-26 IREV.10/83 <br /> EN 1416 J 1 f-5t DO c'.`J .—"'I `` � <br />