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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> PERMIT 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. <br /> kJob Address <br /> ff City t Size PM <br /> d <br />` Owner's NameGt/z. CQIeF� yf address /3 s <br /> Contractor's Name License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑' Phone <br /> WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_.. PITS/SUMPS l� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> us <br />! ❑ Indtrial <br /> ❑ Open Bottom <br /> Domestic/Private "Gravel Pack 12 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Tracy Type of Casing__ /Dj4 <br /> ❑ Public Specifications � <br /> ❑ Other ❑ Delta Depth of Grout Seal 1 <br /> C1Irrigation _Jq Type of Grou <br /> pprox. Depth ❑ Eastern Surface Seal Installed by � <br /> f Repair Work Done C] Type of Pump H p <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 5011 N <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r <br /> Installation will serve: Residence� Commercial, "Other available within 200 feet.) <br /> S <br /> Number of living unitsNumber of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Method of Disposal <br /> r Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size 7 <br /> FILTER BED ❑ Distance to nearest: Well Foundationr� <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPSNumber V1 <br /> DISPOSAL PONDS <br /> ❑ Distance to nearest: Well Foundation Property Line S' <br /> E3 , <br /> 1 <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. !I <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 <br /> tion laws of California." P p Y Persons subjact to workman's compensa- <br /> The appIk must call for all reqyjnd inspection Complete drawing on r verse side. <br /> Signed a <br /> Title: a <br /> Date: <br /> FOR DEPARTMEN E ONLY <br /> Application Accepted by <br /> i Data 1 Area <br /> � 1 � <br /> Pit Grou rispection by Date —�� Final Inspection by <br /> •", •� Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi-X369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copfei.toi5'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE t <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> CASH DATE PERMIT'NO. <br /> +EH 13-24(REV.10183) 11 .. G` 1 <br /> EH 14-26 01 7 CS '"C �Z� _7 -pgO <br />