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APPLICATION FOR PERMIT I <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TY.EAR FROM DATE ISSUED <br /> (Complete in Triplicate) �S �:- ®-3 ,- <br /> f <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�s <br /> h San Jo q�uin/C�oun Doi nceNo�+5499 for sewage or No. 186 o um ell/pnd the Rules and Regulations of the San Joaquin <br /> made in compliance wit <br /> Local Health District. ��j <br /> LOS Size PM <br /> City <br /> Job Address <br /> f Address 01) �� f �` Phone <br /> I Owner's Name '. <br /> n rdss License No. Phone <br /> sContractor Add � <br /> TYPE OF WELL/PUMP: , NEW.WELL ❑ WELL REPLACEMENT ❑ ESTRUCT�ER ❑ <br /> PUMP INSTALLATION ❑ �:w SYSTEM REPAIR L] <br /> DISTANCE TO NEAREST: SEPTIC TANK �. 'SEWER LINES " f'" " DISPOSAL FLD. PROP. LINT , <br /> ,,,-_.FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> '*41NTENDED USE; TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS I <br /> Q Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ipia. of Well Casing �i <br /> 1-1 Domestic/Private ❑ Gravel Pack ❑ Tracy <br /> Type of Casing Specifications i ad <br /> f� Other Cl Delta Depth of Grout Seal Type of Grout <br /> f"1 Public = <br /> I i Irrigation —..Approx. Depth I,I Eastern Surface Seal Installed by G <br /> st H P State Work one— <br /> Repair Work Done EI Type of Pump <br /> Well Destruction Well Diameter Sealing Material "(top 50'1 <br /> t Depth Filler Material "(Below 50'I <br /> system <br /> TYPE OF SFPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION i I DESTRU ION i l (No <br /> vailablerwthin 200 feetit'ed if public sewer is <br /> Installation will serve:'"Residence_ Commercial=Other ' � <br /> Number of living units: — Number of bedrooms �I <br /> yWater table depth k <br /> Character of soil to a depth of 3 feet: <br /> I SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments l <br /> l Method of Disposal <br /> l P_KG. TREATMENT PLT. ❑ i <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines e Total length/size <br /> t <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line I "' <br /> s ` <br /> m-`S EEPAGE PITS i I Depth Size Number + <br /> SUMPS [-IDistance to nearest: Well FoundationPro a on� Property Line <br /> DISPOSAL PONDS ❑ 61 <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 /> rtify that in the performance of the work for which this permit issued, f shalt not <br /> Home owner or licensed agent's signature certifies the following: "I ce <br /> l compensation laws of California."Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's <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 must call for all r wired inspections. omplete drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> l Area <br /> f Application Accepted by Date <br /> �,� s <br /> Pt or Grout inspection by .' <br /> in <br /> Inspection by Date <br /> Additional Comments: <br /> E] Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ElTracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P D. Sox 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO 7 f 2 <br /> + EH 13-24 1REv. i 8.5) / 3/ <br /> EH 14-2e <br />