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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 /> 11PERMIT 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. k� <br /> Job Address Y �j <br /> t�I Ci Lot Siz�'�'( PM <br /> Owner's Name (0^ Address � A� Phon <br /> Contractor �"�"' 4 ' 1 <br /> Address License No.-� � �Pho <br /> TYPE OF WELL/PUMP: n NEW WELL O WELL REPLACEMENT❑ f DESTRUCTION EI 1 <br /> �.' PUMP INSTALLATION r7l SYSTEM REPAIR El OTHER <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 ED Open Bottom.,.,.....,.❑ Manteca Dia. of.Well Excavation Dia. of Well Casing <br /> i <br /> ❑ Ddmestic/PrivaEe. ,,„...,❑-Gravel.-Pack ❑ Tracy Type of Casing Specifications <br /> 1-1Public11 Other 171 delta Depth of Grout Seal Type of Grout <br /> 1 Irrigation _..Approx,.bepth I I Eastern Surface Seal installed by 1 ; <br /> Repair Work Done ❑"""Type of PumpiI H.P, State Work Done_ <br /> Well Destruction ❑ Well Diameter - Sealing Matetial-(top 50`). 1 <br /> Depth Filler Material (Below 50'1-x--1' I <br /> TYPE SEPTIC WORK: NEW INSTAL TION 1VREPAIR/ADDITION I':I*;:DESTRUCTION I } INo septic system permitted if public sewer is <br /> I �_ * . ' i q;# � ,dam <br /> ".f available within 200 feet.) <br /> Installation will serve: Residon ? Commercial_ Othor r t # <br /> ,. <br /> Number of living units: Numfier o bedrooms <br /> Character of soil to a dep of 3 feet:r do �_J Water•table depth <br /> SEPTIC TANK LIType/Mfg Capacity- ' 'No.Compartments IN <br /> E PKG. TREATMENT PLT. ❑ �..�,�..,� t Method of Disposal r <br /> t Distance to nearest: Well dh Foundation'` Property.Line .. ` <br /> LEACHING LINE Eff- No. & Length of lines — '^ _ Toi ,! ngth/size <br /> FILTER BED ❑ Distance to nearest: Well, o o .,,- a <br /> � �'1 roundatio� hro�p�erty Line <br /> SEEPAGE PITS I I Depth - tYl� Size f Number <br /> 1 SU P5 CI Distance to nearest: Well.. Foundation `Property Line f <br /> k ' DISPOSAL PONDS 'T� .-0 <br /> 1 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 k <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 tiecome subject to workman's compensation-laws of California Contractors hifing or sub-contracting signature <br /> r <br /> -t A, 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'applica ust call for re qu i spections. Complete drawing on verse side. <br /> r i <br /> Signed Title: y Date: <br /> r _ OR DEPARTMENT USE ONLY <br /> Application Accepted by Date P C Area t <br /> Pit or Grout Inspection byT Date Finale inspection by Date/ <br /> { Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 1-1Manteca 823-7104 '❑`Tracy 835-6385 <br /> Applicant' - Return all copies to: Environmental Health Permit/Services 1601 E?Helelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i . ■ y f. � f � ro a. ♦w a , <br /> k IEEEO AMOU00 NT DUE +) AMOUNT REMITTED CASH RECEIVED BY DATE' �J PERMIT'NO. <br /> ; _ <br /> ,+ EH 14-244REV.iiH b) .V� �.� V ie, �ft� 1/ [r\ <br /> - t <br />