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II <br /> II ~ APPLICATION FOR PERMIT <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> li 1601 E. HAZEL T ON 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 <br /> made in complianceapplication is <br /> 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. ,I <br /> ] [� r���'3� 'i'ti: .r. � <br /> Job Address ! Ea?. •il'_ �� � Ci C. <br /> f Lot Size PM <br /> Owner's Name Address S• l_ /f Phone — eci1 <br /> Contractor li Address ; <br /> ' License No. Phone - <br />[ TYPE OF WELL/PUMP: i� NEW WELL ❑ WELL REPLACEMENT ❑. DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ ,i .,SYSTEM R 1R'17 y; OTHER ❑ <br /> ,,._...DISTANCE.TO NEAREST:.-SERTIC_TANK -SE R LINES_ <br /> DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRIC TUBE LL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS <br /> a ❑ Industrial ❑ Open Bottom ❑ Manteca Di of Well Excavation Dia. of Well Casing <br /> 171 Domestic/Private El Gravel Pack ❑ Tracy Type f Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth o rout Seal% . M- -Type-of Grout J <br /> { <br /> Ll Irrigation °i Approx. Depth ❑ tern Surface Se Installed by <br /> Repair Work pone ❑ Type of Pump H.P. F, State Work Done t <br /> Well Destruction ❑ Well Diameter " t• <br /> j Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTON ( sevailable within 200 feet.) <br /> o ptic system permitted if public sewer is <br /> a <br /> Installation will serye: Resnce Z _ her <br /> Number of living units: —lrideCommercial Ot <br /> — NumberQf bedrooms 2, <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, ❑ I 1 <br /> ` Method of Disposal <br /> ' Distance to nearest: Well ` 3 <br /> I Foundation Property Line <br /> II y <br /> LEACHING LINE ❑ No. & Length of lines r <br /> Totallertgth/size <br /> FILTER BED 9 ❑ Distance to nearest: Well Foundation Property Line <br /> I� ; <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS <br /> Property Line <br /> [Iti,� t <br /> hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of ttie San-Joaquin Local`Health District. s --- { <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."Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall <br /> tion laws of California." -II em Pto <br /> Y persons subject.to workman's compensa- <br /> TheyYtli" r aI re ui Y ' <br /> \ q pections. Complete drawing on reverse side. <br /> Signed �+� � 47 <br /> Title: C L pate: <br /> II FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area 053 <br /> i� <br /> Pit or Grout Inspection by ! Date Final Inspection by D e <br /> Additional Comments: -C <br /> ❑ Stk 466-6781 ❑ Lodi 11369421 ❑ 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 AMOUNT REMITTED CK RECEIVED BY <br /> INFO` CASH DATE PERMIT N0. <br /> EH1&24'IREV.I/e 57 <br /> EH 1428'' 9'+�.. <br /> i <br />