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. t <br /> APPLICATION FOR PERMIT E- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Rye ' IlGUdJ <br /> f 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T'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 _I DSJ <br /> l! 0w City Lot Size Jtoo PM <br /> Owner's Name —[ , Address Al 4'4Lt Phone <br /> Contractor Address—A �J/yl[sLsa-t~ License No.L"' Z Phone $ <br /> TYPE OF WELL/PUMP: . - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing <br /> ❑ Domestic/Private ❑-Gravel Pack ❑ Tracy Type of Casing Specifications <br /> r <br /> ('1 Public (-1.Other (1 Delta Depth of Grout Seal Type of Grout _ <br /> r I 1 Irrigation _,Approx. Deptha! I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 " <br /> Depth Filler Material (Below 50') F <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION ! I DESTRUCTION I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other - <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg s Capacity" No. Compartments <br /> PKG, TREATMENT PLT. ❑ 1Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines 'r Total length/sizer <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Fl. Depth - Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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. i <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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicantmust 11 for all required inspections. Complete drawing on reverse side, <br /> i CJ <br /> Signed X Title: Date: <br /> ��/,.,/r1t FOR DEPARTMENT USE ONLY <br /> Application Accepted by r ` date ° o r ov7 Area <br /> Pit or Grout Inspection by Date Final Inspection by� Date �^ I <br /> Additional Comments: h <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2019, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. I <br /> t-EH 13-24/REV,1/8 51 r 00 <br /> EH 14-28 c � � / � •+� ` 6Q•-�� ,,: 7 t <br />