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APPLICATION FOR PERMIT <br /> I 41 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E-k—HAZECTON AVE., STOCKTON, CA <br /> Telephone (2091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i <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 /> � ounty Ordinance No.549 far sewage or No. 1(362 for well/pump and,the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin C <br /> Local Health District._ <br /> / eSy/(_ City Lot Size PM <br /> Job Address V �^• S <br /> Phone � ~+ 6 Q <br /> G Address <br /> Owner's Name _� C . <br /> # G57 <br /> I Q Apx_ rf Z 7 License No.11 9 73 _Phone <br /> Contractor .e` - ►'T•1 1pddress <br /> . TYPE OF WELL/PUP F NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR G4 OTHER El <br /> DISTANCE TO NEAR?=ST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FI-D.- PROP. LINE <br /> l i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE 1 TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS <br /> I ❑ Industrial 11 Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Well Casing <br /> 1 <br /> of CasingSpecificationsM/Domestic/Private 11 Gravel Pack ❑ Tracy ;,,Type <br /> OEher n Delta Depth of Grout Seal Type of Grout--- <br /> n Public , <br /> I 1 Irrigation �.Approx. Depth I 1 Eastern "" 'S�Hca Seal Installed by <br /> �`_""" _' - �� "H.P. ` State Work Done <br /> Repair Work Done LR" Type of Pump -..��" - <br /> Well Destruction Cl Weil Diameter Sealing Material (top 50'1 <br /> Depth FiH�r�Material (Below-50'1, <br /> TIC WORK: NEW INSTALLATION l I `REPAIRIADDITION i.) DESTRUCTION f1 (No septic system permitted it public sewer is <br /> T�PE.OF SEP <br /> k i available within 200 feet.f <br /> k Installation will serve: Residence Commercial Other 7I <br /> Number of living units: -r- Number of bedrooms <br /> Character of soil to1adepth of 3 feet: Water table depth <br /> SEPTIC TANK I/,�I"Type/Mfg Capacity 1 - No. Compartments <br /> k I 'y Method-of Disposal <br /> PKG. TREATMENT PLT:❑ {. U\ <br /> I `• Distance to nearest: Well Foundation `P"roperty Line ` <br /> LEACHING LINE t ❑. No. & Length of lines Total length/size <br /> FILTER BED „r-. [I Distance to nearest: Well Foundation perty Line <br /> SEEPAGE PITS i I Depth Size Numbe'r/� <br /> SUMPS L� Distance to nearest: Well Foundation I t <br /> Property Line <br /> t DISPOSAL PONDS ❑ <br /> l <br /> lThereby certify that I have prepared this application and that the work will be done in accordancelwith San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. r <br /> Home owner or licene8 a t s signature certifies the'f'ollnvving:'`I certify that in the performancefaf"the work toy which ffiis permit is issued, 1 shall not <br /> employ any person' uch ma nor as to became subject to orkman°s compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the Poll rng: "I certif that in the performance of the work for which this permit is issued, Isha11 employ persons subject to workman's compensa- <br /> tion laws of lifornia." r <br /> The applic t mus c r requ- pl drawing o:*I--. <br /> side <br /> i �� Date: +` a� lSigned Title: E <br /> FO EPARTMENT USE ONLY ` <br /> I � Dater <br /> Application Accepted by r <br /> Pit or Grout Inspection by Date Final Inspection by�! <br /> I Data 1 <br /> 4 3 <br /> Additional Comments: d <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El 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 REMITTER CK 0 CASH RECEIVED BY DATE PERMIT NO" <br /> INFO <br /> -yah/7C�' <br /> +-EH 13.24(REV.1/"51 •.�+ 1 CIO (70It V5� <br /> EH 14-26 <br />