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1 <br /> APPLICATION FOR PERMIT ° , <br /> L SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> f PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> M : • lr,. w+w = a� M, (Complete in Triplicate) <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 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; :.;ra <br /> i L ' Lot Size PM <br /> Job Addres� -S �" � City <br /> -� <br /> 0 e sNa e IL tf C� ddress `�r J Phone <br /> n .._ <br /> kA <br /> Co a Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> f PUMP INSTALLATION SYSTEM REPAIR L1OTHER ❑ <br /> DISTANCE TO iNEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_____,,. Specifications 1 <br /> El Public t❑ Other ! ❑ Delta Depth of rout Seal Type of Grout 1 <br /> ❑ Irrigation �pprox. De th ❑ Eastern S y Seal In to <br /> ,l 1 <br /> Repair Work Done El Type of Pum H.P. 5tate Work-I]one <br /> Well Destruction ❑ Well Diameter Sealing Material atop 501 <br /> Depth Filler Material (Below 501 'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ElDESTRUCTION ❑F(No septic system permitted if public sewer is <br /> j r available within 200 feet.) <br /> Installation will serve:,,,,Residence—_Commercial <br /> Number of living units: } Number,of bedroorris <br /> - - ., J ..._ _ r <br /> Character of soil to.a aep1l of'3 feet:`' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT_. 1­7Method of Disposal <br /> ( Distance to nearest: Well 'Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 4{ p Depth I Size Number <br /> SUMPS s.a ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS I ❑ <br /> I hereby certify thatf 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 /> Home owner or licensed agent's signature certifi s 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 becom sub' ct to wor r an's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fallo ing:"I certify that in the pert rma de of the ork for which t ',permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of C �fornia." !/ <br /> The applica mu call or I eq 'e inspe io s. Comp to drawing o ve" ide. <br /> -' ��' - - Date• <br /> Signed _ <br /> 9 OR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit oRonal <br /> ut Inspection by. Date Final Inspection by -- ate [? <br /> Add Co �mrrl ants: <br /> C1 Stk 466-Ml ❑ Lodi 369 ❑ Manteca 823 7104 ❑ Tracy 835&3B5 <br /> Applicant• Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 9, c., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMWN0. <br /> INFO r cy -3112- <br /> `� <br /> + EH 13.24(REV.7/851 se•O� r 1, { �� -3 1 1L- <br /> EH 14-28 <br />