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' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> I Telephone (2091 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 /> i <br /> nty Ordinance No.549 for sewage or No. 1862 for�ll/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin Couf <br /> Local Health District. <br /> Job Address City <br /> its! Lot Size aU -�- PM <br /> V J Phone - r <br /> Owner's Name AddressQ <br /> _ y,_ 1� pp�-- 1 <br /> �7m1 ' Address C/ License Noc71Q0 +�5� —Phone iN <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ r <br /> OTHER ❑ <br /> PUMP INSTALLA�TIO�-N, ,X SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAN KQ SEWER LINES DISPOSAL PLD. PROP. LENS L��r� <br /> FOUNDATION AGRICULTURE WELL S OTHER WELLkl—o PITS/SUMPS �d i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS S <br /> Dia. of Well Casing <br /> ❑ industrial Ll Open Bottom ❑ Manteca Dia, of Well Excavation ; <br /> Type of Casing h Specifications <br /> )kpomestic/Private Grave! Pack ❑ Tracy YP g Type of Grout <br /> Other "t ❑ Delta Depth of Grout Seal ( �1 <br /> FI 1 Public ( I <br /> I i Irrigation — Approx:ID e th I I Eastern Surface Seal Installed by <br /> `. <br /> Repair Work Done 64 "Type of Pump �1-r H P State Work Done <br /> t <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 , <br /> ,.Depth I Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTION i I (No septic <br /> lable sy t m refeetnted if public sewer is <br /> avaInstallation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedroomsWater table depth <br /> I <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> ' Total length/size Cam_ <br /> LEACHING LINE ❑ No. 8, Length of lines <br /> FILTER BED EJDistance to nearest Well Foundation Property Line <br /> SEEPAGE PITS I I Depth I Size Number 1 <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line 1�! <br /> DISPOSAL PONDS ❑ <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: 1 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 subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa- <br /> tion laws of California.' <br /> The applicant, u call for all re ired ins ti ns. Completed ing on verse side. fy 7 <br /> Signed X <br /> Title: r' Date: <br /> i OR DEPARTMENT USE'ONLY <br /> Date al Are <br /> Application Accepted by r_ j <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date �o <br /> Additional Comments: 40 <br /> ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Mant a 823-7104• ❑ Tracy ,835-6385 <br /> Applicant - Return all copies to: Environmental'Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA,35201 <br /> FEE--AMOUNT IDUff, `'AMOUNTREMITTEp" RCK­ "' FiEGEIVfD 6Y�+ 'DATE "PERMIT NO. <br /> INFO <br /> ` } <br /> r.EH 13-211REV.t/H51 l{O i V� r <br /> 1 <br /> EH 11-28 _ <br />