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APPLICATION FOR PERMIT p <br /> SAN JOAQUIIV LOCAL HEALTH DISTRICT t <br /> 1601 E. HAZELTON 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 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. �... <br /> Job Address J= = y fVA) _ City RO _.Lot Size PM <br /> Owner's Name <br /> Phone <br /> Contractor's Name C0".S SL:n L___ License No. A�2 Phone f L� <br /> iTYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ % I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ rl�: <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION I AGRICULTURE WELL OTHER WELL j PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r � —cl —Y <br /> i❑ Industrial,.- ❑ Open Bottom ❑ Manteca 4r Dia: of Well Excavation I Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' <br /> _ Yp 9 Specifications <br /> .L] Public ' ❑Other ` ��❑ Delta Depth of Grout SealType of Grout <br /> ,E) Irrigation �4pprox. Depth ❑ Eaastern Surface Seal Installed by <br /> .Repair Work Done Ej Type'of Pump # H.P. State Work Done i <br /> 'Weil Destruction ❑\11 Well Diameter jf Sealing Material (top 601 ; <br /> Depth I Filler Material (Below 501 R �" <br /> (TYPE OF'SEPTIC WORK,: NEW INSTALLATION ❑ REPAIR/ADDITION CJ DESTRUCTION ❑ {No septic system permitted if publie,sewer is <br /> available within 200 feet.) . <br /> I# ::;� .t <br /> Installation will serve: Residence ` Commercial_ Other `' �' ✓ <br /> Number of living units: g Number of bedrooms_ A <br /> Water table depth <br /> Character of soil to a depth of 3-feet:•• _ T- -'- � , '� � _ti�-- 1 '�-- <br /> SEPTIC TANK ❑ Type/Mfg NA Capacity— No. }, <br /> r"VPKG, TREATMENT PLT. ❑ --� Y � Method of Disposal) <br /> Distance to nearest:, Well Foundation Property Line f <br /> •.LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 1$ Distance to nearest: - t WeII LA I Foundation ?IQ' Property Line rbi t <br /> SEEPAGE PITS ❑ Depth E Size �� Number r <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line I <br /> .DISPOSAL PONDS ❑ r, ' <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, ,r 'work. <br /> � �.� i <br /> Home owner or licensed agents signature certifies the following: "1 certify that,in the-per#arinance of the work.for.which.this.permit.Is issued, I shall not <br /> employ any person in such mariner 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, I shall employ persons subject icr'wo-rk"tan's compensa;' <br /> tion is of California." } # / s <br /> ;Thea plica m call for all quired i ns. Complete drawing on reverse sides <br /> Signe t Title: 0 '— Date: <br /> FOR DEP RTMENT USE ONLY <br /> =Application Accepted by f D#by -. <br /> 9 Area <br /> 1 <br /> L7 <br /> ,PiY or Grout Inspection by Date Final InspectionDate r <br /> €Additional Comments: ; <br /> I❑ Stk 466 781 ❑ Lodi 369-3821 11 ❑ Manteca- 1323=7104,F4¢;.D'Tracy J 1335- .� s`vt z jf��,1.57i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> —INFO. _`AMOUNT DUE """ —AMOUNT-REMITTED:---�CKA*CA5HRECEIVED BY '^DATE —PERMIT-NO.- <br /> EH 13-24(REV.10183) ��� ,._ 3 r <br /> EH 1428 <br />