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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> { 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1',YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the Sari Joaquin Local Health District for a permit to construct and/of 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. <br /> r <br /> Job Address + A 1 Y f l Cit r. l� Lot Size / PM <br /> r 4 tv+ Hw 1 qq Phone <br /> Owner's Name Address <br /> } , , Q� `7(07 a�� (� Stas <br /> F Contract Address -_<� Licertse No. Phone <br /> + TYPE OF-WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl <br /> l <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE, <br /> su: r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �- <br /> INTENDED(USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> © Industrial `r, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private '❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1`1 Public Cl Other ) Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation i, _.Approx. Depth <br /> 11 Eastern Surface Seal Installed by _ r <br /> 1 <br /> Repair Work Done Type of Pump H.P. State Work pone <br /> Well Destruction ❑ Well Diamdter Sealing Material (top 50') <br /> Depth r Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR ADDITION Pr DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> ✓% available within 200 feet.) <br /> Installation will.servb" -Residence_ Commercial Other <br /> Number of living units: - !: Number of b drooms _ <br /> Character of soil to a depth of 3 feet: Watetable depth <br /> / <br /> SEPTIC TANK ❑ Type/Mfg Capacity - "^ No.-Compartments <br /> .r• <br /> PKG. TREATMENT PLT. ❑ s* Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ,mow.. <br /> f LEACHING LINE I'No. & L`ength of lines/— notal length/size X <br /> FILTER BED ❑ Distance to nearest: Well�� Foundation JO Property Line <br /> SEEPAGE PITS iOi"Depth I 5 Size� Number <br /> f .--ce. —ea �. r <br /> SUMPS L7� "Distance to nearest: Well .f So Foundation /d Property Line�. <br /> DISPOSAL PONDS Ll <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 /> 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 /> 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 work for which this permit is issued,1 shall employ persons subject to workman's Compensa- <br /> tion laws of California." <br /> The applicant m%tcall,,,forre wired inspections. Complete drawing on rev rse side.r� <br /> } Signed X Title: __ P, Date: • <br /> f FOR DEPARTMENT USE ONLY <br /> 'r <br /> Application Accepted by Date 6� Area <br /> � f <br /> + it r Grout Inspection by Dat Final Inspection by Date <br /> 01 <br /> f Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> ° Applicant - Return all copies to: Environmentai Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE It <br /> INFO AMOUNT DUE AMOUNT REMITTER CASH RECEIVED BY DATE((( PERMIT'NO. <br /> r EH 124 1 REY.%/851 <br /> r EH 144.28 SS// <br /> t <br />