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�r <br /> APPLICATION FOR PERMIT r <br /> -7 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> So 1601 E. HAZELTON AVE., STOCKTON, CA <br />'yJ j cy h.J Telephone (209) 466-6781 <br /> "�` �^ Yo—v­- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED� (Complete in Triplicate). t. <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.a <br /> Job Address S DAVE. City -5TeAl- Lot Size <br /> PM <br /> f Owner's Name /7/Y �� Address x/11 Phone 7" 7 <br /> Contractor .S Address 1olb1�Jcp_XLicense No.� Phc.lcpCp - 2 <br /> _ one <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ 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 /> k ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Wel! Excavation Dia. of Well Casing ! <br /> I <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> C7 Irrigation <br /> ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done GO <br /> Well Destruction V Well Diameter _ Sealing Material (top 50') ic AJ A24,9S <br /> Depth Filler Material (Below 50') <br /> TYPE OF-SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200•feet:.1 <br /> Installation will serve: Residence_ Commercial <br /> ' —Residence.— <br /> Number of living units: Number of bedrooms r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal ' <br /> j Distance to nearest: Well .Foundation Property Line <br /> l <br /> LEACHING LINE ❑ No. & Length of lines 1• `Tota! length/size ' <br /> FILTER BED C7 Distance to nearest: Well . Foundation r Pfoperty Line <br /> SEEPAGE PITS ❑ 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. <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 sut-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 app=mc _a required ' tions. Complete drawing on r ide. r� <br /> Signed Title: S Date: z� / <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by AllkDate 5-00, Area `r <br /> i <br /> Pit or Grout Inspectio by lid ' - Date Final Inspection by' Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 95201 <br /> FEE AMOUNT DUE(REV.t/e51 <br /> AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT`N0. <br /> EH 3-24 <br /> INFO CASH <br /> + EH 14-26l� <br />