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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 /> qC <br /> r Job Address ! /of/t/•tl I 'C - - City Lot Size 6 PM <br /> k <br /> Owner's Name% Address Phone <br /> " Contract Address I. License No 3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ . <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Grave( Pack ❑ Tracy Type of Casing Specifications <br /> (`l Public F1 Other 17 Delta Depth of Grout Seal Type of Grout _. (� <br /> I i Irrigation ,-A'pprox. Depth I 1 Eastern Surface Seal Installed by <br /> ,11 . t j --- <br /> Repair Work Done E] Type=of Pump-- H.P. State Work Done _ n <br /> k Well Destruction ❑ Well Diameter +Sealing Material {top 501 <br /> Depths Filler Material (Below 50'i 1 4 <br /> TYPE-0F SEPTIC WORK: NEW INSTALLATION . REPAIR 7017ION 1 I DESTRUCTION.t•I (No,septic system permitted if public sewer is <br /> available-within 200-feet.) ^te r <br /> Insta3lation wiper e.CRTs d`ence Commercial Other <br /> Number of living units J Number of ooms /�y <br /> Character of soil to a depth of 3 feet: 1 :� •' • Water table depth A00 <br /> ., .fT'f V <br /> SEPTIC TANK :Type/Mfg '*•�`"-Capacity_- No. Compartments <br /> PKG. TREATMENT PLT. ❑ _ f `a Method of Disposal <br /> ;'Distance to nearest: Well Foundation Property Line`Z.577!_ <br /> LEACHING LINE 'Ui!�lo. & Length of lines 1� Total length/size c' X n <br /> f <br /> FILTER HED 5,61 <br /> ❑ stance to nearest: Well_�� Foundation _ Property Line I <br /> SEEPAGE PITS' to Depth Size * Number ` <br /> SUMPS ..: Cl Distance to nearest: Well lJi-Foundation IQ___ Property,Line `s n <br /> k DISPOSAL PONDS © <br /> I I hereby certify that I have prepared this application and'fhai t6 work will-be`done in accordance with San-oaquin daunty ordinances,state laws, and <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 become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> C 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 applicant mu all for ail uir inspectibns. Complete drawing on reverses Q <br /> r Signed X f Title: 0 � • Date: Q �� <br /> r FOR D ARTMENT USE ONLY f"� <br /> Ap )(cation Accepted by Date Area <br /> d <br /> it r Grout Inspection by' Date . _ Final inspection by' Date72 <br /> dditional Comments: <br /> C1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY' DATE PERMIT'NO. <br /> ' INFO CASH <br /> o174 �7 <br /> + EH 13-24 IREV.i/x 51 <br /> �. <br /> 01 <br /> EH 14-2t3 <br /> i <br />