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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE10 ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> k j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) This,a1cation is <br /> he work <br /> rein <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> permit to construct and/or inataldl the'Rufesand Regulations of�S�Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for:well/pump <br /> Local Health District. 0 PM <br /> lLot Size <br /> ` 3 G`�' 1 <br /> i Job Address ' d r <br /> Phone <br /> k Address <br /> Owner's Name r � phone <br /> All <br /> ',.. nae No. <br /> Address DESTRUCTION ❑ <br /> Contractor WELL REPLACE <br /> F WELLIPUMP: WENT 11-3N WELL El WELL ❑ <br /> TYQE O + SYSTEM REPAIR ElPUMP INSTALLATION ❑ DISPOSAL FLO. P. LINE <br /> SEWER LINES �- PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER --- <br /> I FOUNDATION �� CIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUGTI pia. of Well Casing <br /> p' efl Excavation <br /> ❑ Bottom❑ Industrial C5 Manteca Specifications <br /> ❑ Trac Type of Casing <br /> ❑ Domestic/Private [IGravel}Pack alta Depth of Grout Seal Type of Grout <br /> ❑ Public ❑ Other ,. <br /> . Depth [I Eastern Surface Seal Installed by Y. <br /> ❑ Irrigation 4i H.P. State Work Done . <br /> Repair Work Done ype of Pump �� v1 <br /> ❑ Well Diameter Sealing Material (top 50'1 <br /> Well D ion Filler Material [below 50'1 <br /> } Depth <br /> t �, available within 200 feet.) <br /> TYPE OF SEPTI WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION'❑ iNo septic system perrriitted'rf public sewer is <br /> 1 Other�� r <br /> k Commercial i f R <br /> Installation will serve: Residence � f <br /> ` Number of bedrooms �; Water table depth <br /> _ <br /> Number-of living units:�— <br /> t y Character of soil to a depth of 3 feet: * q. Capacity //�l� Q_ No. Compartments <br /> SEPT �� ❑ Type/Mfg' p �'�`�` Method of Disgpsal <br /> � . J <br /> PKG.TREATMENT PLT. ❑ %t Foundation Property Line <br /> l ` ' Distance to nearest: Wel{ <br /> —Ira length/size D <br /> LEACHING LINE ❑ No. & Length of lines property Line — <br /> ( Fourida`tion (� <br /> FILTER BED ❑ Distance to nearest: Well f'"� (\^ <br /> SEEPAGE PITS r10_-Depth <br /> /7 —Size Number <br /> --!2— <br /> MPS <br /> CrY.�Qistance to nearest: Well�n <br /> Foundation� Property Line <br /> DISPOSAL PONDS ❑ ;� <br /> { hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's, certifies the fallowing: "1 certify that in the performance of the work for which this permit is issued, I aha not <br /> rsons subject to workman's compensa <br /> employ any person in such manner as to become subject to workman's compensation laws�of Califomla." 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,1 shall employ PB 1 <br /> tion laws of California." 174 r <br /> The applicant must call for I e wired inspections. Complete drawing o side. pate: r <br /> I;prTitle: <br /> Signed r ' <br /> FOR,DEPARTMENT USE ONLY <br /> sDate Area <br /> Application Accepted by e r Data 1 L <br /> Pit or Grout inspection by <br /> Date Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi) 369-3621 ❑ Manteca 823-7104 Tracy 835-M <br /> Applicant- Return all copies to: Environmental Health Permif/Services 1601 F. Hazelton Ave., P.O. Box 2009, $tk., CA 95201 <br /> +� CK RECEIVED BY DATE PERMIT NO. <br /> FEE aUNT AMQUN7 REMITTtrD CASHINFD+ EH 1324IREV.1/a 5) <br /> EH 1429 <br />