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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTHI 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 /> I <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 fo`r well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> r <br /> +� <br /> City Lot Size PM <br /> Job Address !` <br /> �C) Phone <br /> + Owner's Name. o Address p+� ` 74 �i <br /> ' ` ' Rt�c�l CQph <br /> Contract <br /> r Addres., License No: <br /> TYPE.OF WELL/PUMP: NEW WELL LJ WELL REP <br /> LACEMENTp ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRS'❑ OTHER L1 <br /> �I DISPOSAL <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES ,.z FLD._ - <br /> PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL' PITS/SUMPS , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION ISPECIFICATIONS'— <br /> 0 industrial ❑ Open Bottom L1,Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic lPrivate ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Specifications <br /> Other ❑ Delta Depth of Grout Seal Type of Grout_—, <br /> f I Public 1I -f ­ <br /> I I irrigation Approx. Depth I 1 Eastern Surface Seal Installed by - i <br /> Repair Work Done ❑ Type of Pump H.P. M State Work done <br /> I; <br /> Well Destruction D 'Well Diameter Sealing Material Itop 501 <br /> Depth -Iter Material (Below 50'1 # <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION is REPAIR ADDITION DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> f! available within 200 feet-l' <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number bedroo�J s i <br /> Character of soil to a depth of 3 feet: Water table depth '-1 <br /> SEPTIC TANK 0 Type/Mfg CapacityfNo. Compartments <br /> PKG. TREATMENT PLT. ❑ ` Method of Disposal J <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines `Total length/size ' <br /> +J <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 171 Depth Size �M. Number <br /> SUMPS __ .-.. _ Ll Distance to nearest:-, _Well�. Foundation _�PropertY Line�- �^°= <br /> DISPOSAL PONDS 0 <br /> application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this <br /> l rules and regulations of the San Joaquin Local Health District. <br /> t Home owner or licensed agent's signature certifies the following: "I cerfify that in the performance of the work for which this permit is issued, I shall not <br /> 4 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 /> I 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." !!!I <br /> The applicant call f� re ired inspections. Complete drawing on reveV11, <br /> Signed XTitle: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 'T4 <br /> •r -. Date 1_d Area <br /> Odditional <br /> Grout Inspection b,' —� Date , cl IC,D Final 1n pection b Date <br /> Comments: <br /> ' ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 El Tracy' 835-M5 <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 CASH ��RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> I /! <br /> .-EH 13-24 1 REV.I/H 5) <br /> �2-Z— <br /> EH 14-28 Ey <br />