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t. <br /> APPLICATION FOR PERMIT 1 <br /> a SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES-11 YEAR FROM DATE.ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.S49 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health DistricV":rtt, <br /> Job Address 0_3 Cf__3 ,l� /_�.c l.[.B.i. City Lot Size PM <br /> Owner's NameAddress Phone r <br /> i <br /> Contractor Address/.177W ! � <br /> License No��_Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 1 PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ HCl <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 /> ❑ Industrial ❑ Open Bottom 4 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \011 <br /> It Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other } ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done (I Type of Pump!�4.ag Q�! _ H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 4,49 ` <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 71REPAIR/ADDITION ❑ DESTRUCTION - Wo septic system permitted if public sewer is <br /> i available within 200 feet.) <br /> Installation will serve: Residence_ Commercial, Other e <br /> Number of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 feet:: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg,1 CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ + Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No:& Length of lines Total length/size <br /> FILTER BED -- -❑—Distance t6'nearest: Well '..a 'Foundation' Property Line- ' <br /> , <br /> _SEEPAGE PITS. {❑ Depth I t Size "' + rt Number <br /> v SUMPS LJ Distance tornearesr M1 ) Well t =-Foundation Property Line <br /> DISPOSAL PONDS ❑ ;i s <br /> I hereby certify that I have prepared this applicatior}and that 36' 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 /> 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 us call or all required inspections. Complete drawing on verse side.. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY' 9 <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date Final Inspection by p <br /> ate <br /> Additional Comments: l <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621, ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies w Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> �l <br /> FEE AMOUNT DUE IT--AMOUNT REMITTED RECEIVED BY DATE PERMIVNO. <br /> INFO <br /> r <br /> + EH14-24fREV.i/esl <br /> EH 1426 <br />