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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) e work <br /> n described, This ap. <br /> cation is <br /> to <br /> t and/or install th <br /> madecntcompAppliaion isliance withoieby de tSanoJoaqu nthe SanCouQty OrdinaJoaquin lncfe Nth District for a o.549 for sewage or No. 1862 forcwell/pump and the Rules and IRegulationss of the SanEJoaquin <br /> Local Health District. � ,C <br /> / ✓IA7/1 ,� t City Lot Size PM <br /> Job Address <br /> Owner's Name �/ Address G Phone <br /> �GJt .S N Phone <br /> _ Contractor ' WA6l L� -Address License No. <br /> TYPE OF WELL/PUMP: j NEW WELL ❑ WELL REPLACEMENT LIDESTRUCTION ❑ <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 /> W� <br /> INTENDED-.USE',1 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑Industrial ❑ Open Bottom LJ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> L—A -1� <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> - e of±Grout - <br /> (1 Public i� Other Cl Delta Depth'of Grout Seal yP ' ' <br /> I I Irrigation - —._APprox. Depth 1 1 Eastern Surface Seal Installed by <br /> Repair Work'Done ❑ Type of Pump H.P. State Work Done 1 <br /> Well Destruction ❑I� Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below-50'4 <br /> TYPE OF SEPTIC WORK` NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I i INo septic system Permittedwf public sewer is <br /> available within 200 feet.l1 <br /> l <br /> Installation will serve: Residence Commercial"._ Other <br /> r Number of living units:- ! Number of bedrooms t�� <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK A Type/Mfg 3 t P-t•4_ _ Capacity��— No. Compartments k -� <br /> PKG. TREATMENT PLT. ❑ 7 0 Method of Dispo#al <br /> Distance to nearest: Well �C5 Foundation_ Property Line tD <br /> 14 <br /> -tA,_k Total len th/size <br /> I,t LEACHING LINE � Na.•8 Length of lines 9 <br /> FILTER BED ""❑' Distance to-nearest:----Well-_:- .--Foundation—10 .-Property Line- <br /> r SEEPAGE PITS I 1 DepthX t 1. .Number <br /> Size -2 r <br /> SUMPS I,Y"Distan'ce to nearest: Well'�v o •=Foundation ' Property Line" J,] r <br /> DISPOSAL PONDS ❑ �.,�E �� ' ' _ �' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinan les, state laws, and <br /> rules and regulations of the San Joaquin Local Health Diltrict. <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 o"r 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 taws of California." <br /> The applicant must call for a (required inspections. Complete drawing on reverswside. �.,. <br /> Signed r LdyTiNa: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Appli tion Accepted by / Date (9'r�Area <br /> r rout ection by Date Final Inspection by Dat <br /> F----,- <br /> n,� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I <br /> FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +. 4601 <br /> Eli 13-24 IFaEV.1 sl <br /> EH 14-28 <br />