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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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 /> fW J EII'ktta <br /> Jol�,<�'Address City F Lot Size. PM <br /> wner's Name ti Address Ss - Phone _21�.2 <br /> S � <br /> Contractor's Name License No. S / <br /> Phone � <br /> E TYPE OF WELL/PUMP: NEW 7fl I ❑ WELL REPLACEMENT ❑ DESTRUCTION O <br /> PUMP INSTALLATION ❑ SYSTEM.REPAIR 19 OTHER ❑ } <br /> DISTANCE TO NEAREST: SEPTIC TANK F SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i _ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f ❑ Domestic/Private ❑ Gravel Pack El Tracy "j Type of Casing: _ kSpecifications <br /> .� Public' 11 Other _. p Delta Depth of Grout'Seal'-111— � ��' Type of Grout -- <br /> ❑ Irrigation _ _ . • uraceSeaInstalld by <br /> Repair Work pone � Type of'Pump � . St <br /> ate Work Done� H'P. // ' <br /> Well Destruction ❑ Well Diameter 17 Sealing Material (top 50') <br /> Depth /Filler-Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIP/ADDITION F1 DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> �,Installation willll,serve: Residence")Commercial �Other <br /> `+j Number of living units: Numberofbedrooms Y <br /> Character of soil to a depth of 3 feetA-1. Water table depth r <br /> SEPTIC TANK ❑ Type/Mfgf r Capacity No. Compartments - <br /> PKG. TREATMENT PLT, ❑ <br /> Metfiod of Disposal <br /> Distance to nearestt IVAI'I" % * Foundation Property Line <br /> # <br /> I �. <br /> LEACHING LINE ❑ -No. &Length of nes Total length/size <br /> FILTER BED ❑ Distance to dearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number 21 <br /> SUMPS ❑ Distance to nearest: �Wall Foundation—'Property Line T11 ' <br /> DISPOSAL PONDS ❑ <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.. <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 became subject to workman's compensation pensatian laws of California."Contractor's hiring or sub-contracting signature I <br /> certifies the following: "I certify that in the p90Formance 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 must call for all required inspections. Complete drawing on reverse side. <br /> r" <br /> Signed f Title: Date: C9.—'� S <br /> FOR DTPA T USE ONLY <br /> Application Accepted by Date t9 ax ea <br /> Pit or Grout Inspection by Date Final Inspection by y Date <br /> a+ I <br /> Additional Comments: 401"' <br /> Stk 466.6781 ❑ Lodi 369-3621ElManteca 823-7104 ❑ Tracy 835-6385al <br /> Ij <br /> plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE 1 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK 0 <br /> CASH RECEIVED BY DATE' PERMI7NO. <br /> +EH 13441REV.10l931 <br /> EH 1426 �/ <br />