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• s <br /> h <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTONAVE., STOCKTON, CA <br /> Telephone (209) 466-6781 i <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) t <br /> fir w <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 applicatior}.is -_---- <br /> .549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San JJo <br /> made in compliance with San Joaquin County Ordinance Noaquin <br /> Local Health District. <br /> n+ fir; City Lot Siie ��^PM <br /> Job Address ♦I 3 <br /> x <br /> Owner's Name itn Address _� /n� Ph�ione <br /> Contractor Address fid' fi STT License Na. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.-LINE 'Q~' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS h' <br /> INTENDED USE -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ OpenBottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private ❑ Gravel Pack q;❑==.T.racy �[� � ;(Type of Casing Specifications <br /> . + Type. l <br /> LJ Public ❑Other� t ❑-De�ta Depth of Grout Seal Yp .of Grout. <br /> El Irrigation x _ `� Y L pprox. Depth ❑ Eastern Surface Seal installed by <br /> Repair Work Done [IType of Pump,' - H.P. State Work Done <br /> Well Destruction ❑ Well Diameter i' Sealing Material (top 501 } <br /> Depth ! Filler Material.(Below-501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 7,K REPAID/ADDITION ❑- DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence�,_! Commercial_`.Other ' <br /> Number of living units: . Number of bedrooms '��... <br /> t Water table depth <br /> Character of soil to a depth of_3 ff.eet: l - _ <br /> SEPTIC TANK ❑ Type/Mfg . 74-x ' Capacity_PA No. Compartments r <br /> PKG. TREATMENT PLT. 1:1 ``Y```I I ' Method of Disposal ' <br /> Distance to nearest: Weli Foundation �� Property Line <br />+ji' g <br /> TtStal len th/size + <br /> LEACHING LINE 4' No. & Length of lines . <br /> FILTER SED E] Distance to nearest: Well FoundationProperty Line , <br /> j <br /> i. SEEPAGE PITS IDDepth lI Size Number <br /> SUMPS ❑ Distance`to nearest: Well r 'Foundation. Property Line i <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the woRwill be done in accordance with San J aquin 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 /> I employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring csub-contracting signature <br /> certifies the following: "I certify that in the performance'of th'e work for which this permit is issued, I shall employ,person s subject to workman's compensa <br /> tion laws of California." <br /> The applicant must call for requir d inspections. Comple"te drawing on reverse side. <br /> I f© <br /> Title: <br /> Si Date: g <br /> 7 i <br /> + ,.. g i FOR DEPARTMENT USE ONLY + <br /> p �' Q r <br /> L - Date ''� F Area <br /> 'Application Accepted by l <br /> *} Date Final Inspection by Dat <br /> Pit or Grout Inspection by i <br /> G. <br /> Additional Comments: ' <br /> 171Stk 4664M1 E7 Lodi 369-3621 C1 Man 823 7104 ❑ Tracy 83 , > E <br /> Applicant Return fall copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O;'Box 2009, Sik. CA 95201 <br /> FEE —CASH <br /> ypECEIVED BY --7DATE\ PERMIT,INQ. <br /> 4 AMOUNT DUE i_ AMOUNTREMITTEq - <br /> �.w INFO- - <br /> L�s� =[Zo.- _gS 1_s5z -- <br /> 14(REV:-1165) <br /> yyy, <br /> fes' <br />