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APPLICATION FOR PERMIT •k. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> f Telephone (209) 466-6781 <br /> } PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> 1 (Complete in Triplicate) <br /> Application is hereby made to theSan Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is q <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. " <br /> Job Address <br /> 1�?-2 3 City Lot Size <br />! Owner's Name UV r�f /� Add' % � Ph <br /> .?';. i'i i/ w� , t . one - <br /> re'ss"T <br /> J� <br /> 10 <br /> Contractor I Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW;WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTICJANK- SEWER LINES r DISPOSAL FED. PROP. LINE <br /> t <br /> F01JND"ATION �- ---- - AGRICULTURE�WELL-�-"� -�- �OTHER""WELL t PITS/SUMPS <br /> ' INTENDED USE TYPE OF WELL r r PRO$LEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation. Dia. of Well Casing <br /> ❑ Domestic/Private ,,O,Gravel Pack r.F ❑ Tracy Type of Casing 5 Specifications <br /> (l Public rn'Othei e' f.-1 Delta Depth of Grout Seal ' Type of Grout <br /> i'I Irrigation a Approx. Depth l I'E"astern ' .,.�--Surface Seal Installed by" <br /> i Repair Work Done D Type of Pu`mp t" r H,P. State Work!Done <br /> Well Destruction ❑Well Dia a er �` ` { '- _Sealing-Material [top <br /> 5. Depth `! z r Filler Material (Below 50'1 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IT REPAIR IADDITION. DESTRUCTION l I INo septic system permitted if public sewer is <br /> � available within 200 feet.) <br /> Installation willfserve: Reside`a Commercial— other - I <br /> Number-of. units: Number of bedrooms <br /> �'' [ t 4 Water table depth <br /> Cf1ar'act&r of soil to a depth-of 3'feet: r p <br /> I SEPTIC TANK ❑ Type/Mfg G' t Capacity "�t7? No. Compartments <br /> PKG. TREATMENT PLT.,0 Method of Disposal " <br /> Distance to`nearest: Well f Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> f — � Total length/size <br /> g <br /> /FILTER BED 0 Distancesrto nearest: Well_ Foundation Property kine <br /> Y <br /> SEEPAGE PITS Depth t Si Number <br /> SUMPS ❑ Distance to nearest: We --Foundation------­'12Li <br /> Pr perty~ILine <br /> DISPOSAL PONDS ❑ 4;"��' <br /> f Phereby�certify thail have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> f rules'and regulations of the'San JoaquinFLocal 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 shalt 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:'9 certify thatiri'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:pplicant must call for all q 'ed.inspections.-.Complete_drawing:on-rdJerse.side. -,.,.Signd X Title: 0� �� Date: <br /> F��EPARTIMENT USE ONLY <br /> - f�_ Area <br /> Application Accepted by <br /> Pit or Grout Inspection`by Date R" ,1 ' Final Inspection by Date <br /> ,,, <br /> �i <br /> Additional Comments: <br /> ❑ Stk -466-6781 -D-Lodi-369-3621 ❑ Manteca"-823:7104'- ❑ Tracy 8356385 "` """�"� <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave% P.O. Box 2009, Stk., CA 95201 <br /> i <br /> 6 FEE AMOUNT DUE AMOUNT,REMITTED RECEIVED BY 4 DATE PERMIT"No. <br /> INFO <br /> +�EH 13.20REV.1/K 5,• '"`"'^"""-" """" - - r��-' <br /> i 14-26 .`L7- <br /> EH <br /> 3 ) <br />