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n APPLICATION FOR.PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> i Telephone Q09} 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 `` a' City Lot Size AMA, PM <br /> Owners-Name = -'/� r ress„ J l.. Phone <br /> _._ <br /> ---T _. . <br /> Contractor's Name icanse No:'` Phone- V! <br /> TYPE OF WELL/PUMP: NEW WPLL1,1J ' cWELL REPLACEMENT ❑ DESTRUCTION ❑ f} <br /> PUMP iNSTPiL"LA71OfV❑ r !SYSTEM REPAIR ❑ OTHER ❑ <br /> 4. DISTANCE TO NEAREST: SEPTIC:TANK t — .�. SEWER LINES. ~ .,.DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE',bF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open'Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other �,.� ❑ Delta Depth of Grout Seal Type of Grout a <br /> ❑ Irrigation --Approx. Depth ❑ 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 50')�^- Depth Filler Material (Below 501 a - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> i t -,� available within 200 feet.I <br /> #; Installation will serve: Residence_ Commercial Ot er�! G 4- <br /> i <br /> " Number of living units:46- Number of bedroo 1 l <br /> Character of soil to a depth of 3-feet: , t7 <br /> Water table depth ` <br /> SEPTIC TANK O Type/Mfg XL T fW WC Capacity No. Compartments <br /> 1�..n.- r. <br /> PKG. TREATMENT PL'T.'O t+ Method of Disposal, <br /> Distance to nearest: Well x"Foundation Property Line <br /> } <br /> LEACHING LINE ❑ No. & Length of lines O /C1 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth � Size � Number <br /> SUMPS ❑ Distance to nearest:' Well aJfrc/ oundation- 4!12' <br /> � Property Line -nC7: - <br /> 61SPOSALf 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, statelaws, 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 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." j <br /> The applicant must caU r all required inspe tions. mplete drawing on reverses 3 <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> Application Accepted by Date ( � Area <br /> Pit or Grout Inspection by Date 8 Final Inspection byDate <br /> AddRionat Comments: <br /> ❑ Stk 466-6781 ❑ Lodi- 369-3621 0 ❑ 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 AMOUMT LpUE ` }AM <br /> OUNT'.REMr7rED CASH»«» v -RECEIVED BY _ DATE PERMIT NO. , <br /> INFO - .. <br /> + EH 13-24 IREV. 60 <br /> 10/83F - - ,x r - yS <br /> EH 1428 <br /> I <br />