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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT (� <br /> D 0 , 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED ,, # <br /> (Complete in Triplicate) <br /> Application is he+eby made to the San Jol uin 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 /> QIP r <br /> Job Addresser/ "/ _ City � Lot Size -- PM <br /> I/4 `7✓ f / 6 b � Phone is i <br /> Owner's Nam+e�� Address /!' <br /> Contractor 1 _ Address �' License No/ �--� —3 Phone�� b k z <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> t ' PUMP INSTALLATION � SYSTEM RE Alii ❑ OTHER ❑ <br /> C DISTANCE TON REST: SEPTIC TANK 0-0 r SEWER LINES r° STJ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURI WELL OTHER WELL. PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS {t <br /> ❑ Industrial L ❑ Open Bottom ❑ Manteca Dia. of Well Excav 'on r Dia. of Well Casing <br /> p' <br /> Domestic/Private K Gravel Pack ❑ Tracy Type of Casing Specifications <br /> V f l Public, f ❑ Other b' ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx.:Depth) 1 ! Eastern Surface Seal Installed by <br /> i <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> ` Well Destruction O Well Diameter. Sealing Material Stop 501 <br /> Depth Filler Material (Below 501 <br /> VTYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION 1 1 DESTRUCTION i 1 (No septic system permitted if public sewer is <br /> a # available within 200 feet.) <br /> installation will serve: Residence_. Commercial_ Other <br /> Number of living units: Number of bedrooms �a <br /> Character of soil to a depth of 3 feet:^� Water table depth 4 <br /> SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal`' <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE`-. ❑ No. & Length of lines Total length/size <br /> FILTER BED ` ❑ Distance to nearest: Well Foundation x.'Prop erty Line �— <br /> SEEPAGE PITS �Ih Depth ( Size `} T— 3 — Number <br /> SUMPS LI Distance to nearest: Well Foundation- t Property Line \ <br /> DISPOSAL PONDS LJ <br /> 4 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 Di%trict. a ;. 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 compensatibn 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 persons subject to workman's compensa- <br /> tion laws of California." �- <br /> The applicant mu call f r all required inspections. Complete drawing on reversi3 side. <br /> { c� <br /> Signed X I Itle: Date: <br /> { i <br /> I� FO SE'ONLY <br /> r1f <br /> Application Accepted by Date Area <br /> -�, � r0 V <br /> Pit or rou Inspection by t `/� Date Final Inspection by. Date <br />' Additional Comments: � <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 ❑ Tracy 83 -6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 4,1? <br /> jEE AMOUNT DUE' ' AMOUN7 REMITTED`*_` SH RECEIVED BY DATE PERMIT NO.INF <br /> I <br /> L ` qQ'� A <br /> +.EH 13-24(REV.t i n 51 O 5 rQ� cbmr— <br />