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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 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 �L, �zC C� L GCS h wAep ,A U15 City 1WiAlU��� Lot Size �J �G PM <br /> Owner's Name RU Address �d"O �a Phone <br /> Contractor 4, EOLL Address t�0. 1�1 %h+/�+� License No.-:AMTS- Phone <br /> TYPE OF WELL/PUMP: NEW WELL O' WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> r, <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Op Bottom t ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (l Public ❑ Other L7 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I l Eastern Surface Seal installed by ! _ <br /> Repair Work Done ❑ Type of-ftmp H.P. State Work Done'_ <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted it public sewer is <br /> _ available within 200 feet.) <br /> Installation will serve: Residence— Commercial _ Other <br /> Number of living units: Number of bedrooms �N014J4 ' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg •apacity No. Compartments <br /> PKG.�TREATMENT PLT, ❑ F9—f Method of Disposal <br /> Distance to nearest: W611 Foundation !�40 Property Line <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED C1 Distance to nearest:' ; well Foundation W Property Line ��J FT _ <br /> SEEPAGE PITS i I Depth Size h Number ' <br /> SUMPS Cl Distance to nearest: Well fbundation Property Line <br /> DISPOSAL PONDS ❑ i <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 iri 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:,'-1I certify that in the performance of the work for which thisrpermit is issued,i-shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must catl for all req 'red ins tions. Complete d(awing on reverse side. f <br /> /J <br /> Signed X- ``' __ Title: _� -- Date: 7 `e <br /> FOR DEPARTMENT'USE ONLY / <br /> Application Accepted by r Date —� Area [ f <br /> Pit or Grout Inspection by Date Final Inspection by Date �f <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box'1M, Stk., CA 95201 <br /> lFEE AMOUNT DUE AMOUNT REMITTED'—"'CASH-- '`RECEIVED BY DATE' PERM17-N0. <br /> ♦-EH 13-241REV.1/951 n <br /> EH 14-2e <br />