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c, <br /> APPLICATION FOR PERMIT <br /> m r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ]PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) I�QIV g -0 -1 <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. c <br /> Job Address It! ~'S f5�1 ! t�' J _ City ICA Lot Sixe /��'- LAS PM <br /> Owner's Name R1 ! / �sZ Address �ita�J� �O1T / Phone <br /> cont[a�torOPUMP4� Address - LicenseNo.,5Lan -�r,��Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ a <br /> PUMP INSTALLATION Pa' SYSTEM REPAIR ❑ OTHER ❑ j <br /> DISTANCE TO NEAREST: SEPTIC TANK A� 'Z' SEWER LINES Q + DISPOSAL FLD / PROP. LINE X <br /> FOUNDATIO •N tied AGRICULTURE WELL 0� "HER WELL rPITS/SUMPS A?0/_)e: <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G� �3 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> iFl%mestic/Private P15ravel Pack! ❑ Tracy Type of Cas`ng ,� 4, Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout xj <br /> ❑ Irrigation 0_�ApproxJDepth ❑ Eastern Surface Seal Installed by j <br /> Repair Work Done ❑ Type of Pump Isg1iff/17 H.P. ,. State Work Done I <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 ' <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION ElREPAIR/ADDITION C1 DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> i available within 200 feet.) <br /> F--kistallation will serve: Residence_ Commercial Other 0 <br /> Number n units: Number of bedrooms j <br /> Character of soil to a of 3 feet:.: .3 °' Water table depth t <br /> SEPTIC TANK ❑ Type ' - --Capacity----- ,....No. Compartments_ <br /> PKG. TREATMENT PLT. ❑ y <br /> J f MethocE'of Qisposal `"� '� <br /> Distance to�nearest:`G Well oundation Pioperiy Line 3 <br /> LEACHING LINE ❑ No. & Length of linesr j Tota /size { <br /> FILTER BED ❑ Distance to nearest: Well Foundation 1 Property <br /> SEEPAGE PITS ❑ Depth I Size l%� Number <br /> SUMPS" ❑ Distance tc nearest: Well - Foundation ' Property"Line W <br /> DISPOSAL PONDS 13I -! l �L t'`-_ jt - <br /> 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 performarice of the work for which this permit is issued,I shall employ persons subject,to workman's comperisa- <br /> tion laws of California." <br /> The applicant cal for all requiredinspections. Complete awing on reverse side. <br /> Signed Title: Date ~i;P 2-<27 <br /> FOR DEP RTMENT USE ONLY 1 _ <br /> Application Accepted by _ Date Area r OS <br /> t <br /> Pit or Grout Inspection byDate7-,.:i-q-07 Final Inspection by 'Date z y <br /> rrs j <br /> Additional Comments: f I I <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ,IFEE NFO AMOUNT DUE AMOUNT REMITTED H RECEIVED 8Y DATE PERMIT;'N0. j <br /> + EH 3-24(REV <br /> EH 1128 <br />