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Pm 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) <br /> r Application is hereby made tote San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> f 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. J, 'I. <br /> PM <br /> Job Address City Lot Size <br /> Owner's Name Address Phone <br /> Contractor s Address License No.4 Phone�3 <br /> TYPE OF WELL/PUMP: i�. NEW WELL ``"� " WEL0FIEPLACEMENT ❑ DESTRUCTION Ll <br /> ��"""""PC!MP'fNSIAL'I�TI�D�TI%� "� """- ' 'SYSTE-M-REPAiR-FI--- .— OTHER`❑— + <br /> DISTANCE TO NEAREST: SEPTIC TANK �7 Y� SEWER LINES ef= DISPOSAL FLD. PROP. LINE <br /> FOUNDATION Z5+ AGRICUt-TURE•WE L � } OTHER,WELL_ PITS/SUMPS A2 <br /> i Y <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S aK <br /> Dia:-of-.Well->vasin <br /> .� flAradustrial -Q-Open-Bottom - ---•❑•Manteca -•.r 1:T 7Depth <br /> Well Excavation- -- - 9— — <br /> Domestic/Private Gravel Pack` l t G]'Tracy Casing Specifications <br /> f`l Public ( r�O�t�her t❑ Delta f Grout Seal Type of Grout <br /> I I Irrigation 'j_?�'Approx-•.Depth ['I Eastern , Surface Seal Insiatled-b - <br /> Repair Work Done ElType of Pump H.P ,State`Work one <br /> Well Destruction Li Well Diameter `ii l=ga Sealing Material Itop 501 <br /> t Depth f + Fillei Material I Below 50') Y -- <br /> I€ TYPE OF SEPTIC WORK: NEW INSTAL ., <br /> ATIO l 1 '.REPAIR/ADDITION I I DESTRUCTION I 1 INo sepit1system permitted if public sewer is <br /> I� } available within 200 feet.) �. <br /> Installation willserve: Residenc j_ Commercial. Other <br /> F + ,{ <br /> Number of living units �!`� �Number.of beams <br /> Cf4aracter-of soil to a depth.Iho1 3 feet: Water table depth <br /> SEPTIC TANK' ❑ "Type/Mfg -- Capacity i No. Compartments <br /> -v <br /> PKG� TREATMENT PLTI"L"1 �Sf/♦ E i Ash-��'` Method of Disposal <br /> t atstance_to-.nearest: WIk Foundations Property Line <br /> P LEACHING LIlE ❑ No, & Length of lines r 4 Total length/size <br /> FILT1ER BED ❑ bistance to nearest: Well , Foundation Property Line `� r <br /> SEEPAGE P1fS "I I Depth Size Number 41aw,SUMPS Ll Distance to nearest; Well Foundation Property Line <br /> DISPOSAL PONDI he1by certify that I have pitpa�red this•appliicatioriand that the work will be done in accordance with San Joaquin county ordinances, sta <br /> rules and regulations of!the S n-Jni�urn Local=Health District. <br /> Home owner or licensediagen1s, signature-certifies-the 00ving: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> l 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: "licertiifIy 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." 9 <br /> i <br /> The 'applicant requi ons. Complete drawing on re ors, side. d <br /> l Z! O <br /> Signbd X ills: Date: <br /> L.I <br /> FOR DEPARTMENT USE ONLY <br /> r Date Area <br /> Application Accepted by <br /> i Pit or Grout Inspection by Date` Final Inspection by Date <br /> TD <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-361 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies;o: Environmental Plealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK 4 <br /> FEE AMOUNT DUE AMOt7-T REMITTEE] CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> r 4 <br /> +.EH 13-24 EV <br /> EH 14-26 - � <br />