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f <br /> i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 1209) 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 /> y r <br /> 4rf� f i Cit Lot Size PM <br /> Job Address <br /> r _ <br /> I t <br /> Owner's Name .9/" yr �p��[f" _ Address '—por A6,05e 4� +5%hck!�6AI Phone <br /> Ar <br /> i <br /> Contractor �C/S� Address License Nor. �'7k</ Phone <br /> i 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca- Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 171 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout <br /> i <br /> I I Irrigation —.-Approx. Depth l 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 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [-I REPAIR/ADDITION l 1 DESTRUCTION I I INo septic system permitted if public sewer is <br /> 4 available within 200 feet.) <br /> 1 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 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> k � Distance to nearest:' Well* ,­ foundation Property Line <br /> Y <br /> LEACHING LINE 0­1 No. & Length of lines - Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l-I-q' Depth -� Size 7—"1-- Number <br /> SUMPS Ll„;Distance to nearest: Weil Foundation Property Line <br /> DISPOSAL PONDS ❑y <br /> I hereby certify that I havCprepared 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:41 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: 1-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 applicant mu caH for all re d inspections. Com lete drawing on reverse side. �S <br /> t Signed c Title: ��' Date:���/`�~ <br /> R DEPA�RTMEN USE ONLY <br /> ., 4ppfication-Accepted by '" Date Area - - <br /> Pit or Grout Inspection by Date Final Inspection by. J ` Date �Z <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 /> FEEI INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE (� PERMIT N[yO. <br /> +.EH lli4IREV.1/851 W <br /> EH 14-26 - - - \ a <br />