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APPLICATION FOR PERMIT GS <br /> I <br /> SAN-JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601'E. HAZEL T ON AVE.,.STOCKTON, CA NQ W C-_ w oze_ � <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 9 YEAR FROM DATE ISSUED NO �PAl k <br /> (Complete in Triplicate) �,�.� ��� T-_ <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 iis <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. i <br /> Job Address M,1 City I Lot Size ��`� PM <br /> Owner's Name nAddress A -i-� <br /> g4 hone <br /> S��" C <br /> Contract � Address&3� License No �`T�f6 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 FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �^ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA '-,CONSTRUCTION SPECIFICATIONS <br /> Q Industrial ❑,Open Bottom. _ ❑ Manteca-,,,_ ,Dia:,ofWell Excavation _ . .. _--.Dia of-Wel Casing-- <br /> El <br /> asin❑ Domestic-/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public �'Tv ❑ Other ❑ Delta Depth of Grout Seal i Type of Grout <br /> O Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump ` y _�H'P. State Work Done <br /> --Well Destruction ❑ -,Well Diameter Sealing Material (top 50') j <br /> Depth Filler Material (Below 50') � I <br /> t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 73 REPAIR/ADDITION ❑ DESTRUCTIO Wo 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 /> Character of soil to a depth of 3 feet: �` <br /> Wates table depth .� <br /> SEPTIC.TANK ❑ T ��, <br /> ype/Mfg Capacity '­Wo. Compartments f <br /> PKG. TREATMENT PLT. ❑ M f°od of Disposal <br /> Distance to nearest: Well . Foundation Property Line <br /> LEACHING LINE ❑ No.& Length of lines Total.length/size i <br /> FILTER BED. C] Distance-to-nearest-Well •a - - Foundation E Property Line <br /> SEEPAGE PITS ❑ Depth-t/.. Sizek ' .Nmber=' ° <br /> SUMPS ElDis'ta_nco to nearest: Well _ Foundation Property Line ° <br /> DISPOSAL PONDS Q <br /> hereby certify that i have prepared this application and that the`worOWill be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sah�Joaquin Local <br /> Health District. <br /> Home owner or licensed agent's`signature certifies the following:'%'I certify that in�the perfor ace of the work for which this permit is issued, I shalt not <br /> employ any person in such-manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the w_ark for Which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of-California." t 1 toy r 3+ <br /> / j <br /> The appticant all for all requ' inspecti s. Complete drawing on reverse side. <br /> Signed f Title: Date: 7 <br /> ' FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date a Area 19 <br /> Pit or Grout-Inspection by Date Final Inspection by ° Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 '— ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicantf`Return-all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 3 <br /> � INFO CFEE DC <br /> DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. <br /> + EH 1324(REV. /s 51 C - CJ G <br /> EH 14-Z$ <br />