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APPLICATION FOR PERMIT <br /> �i SAN JOAQUIN LOCAL HEALTH DISTRICT 1 � b <br /> : <br /> i� 1601 E. HAZE; TON AVE., STOCKTON, CA SV�o <br /> j Telephone (209) 466-6781 <br /> i <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 /> 3S. s . r I <br /> Job Address E ,.f��— City Lot Sido 9 X-1—So PM , <br /> Owner's Name S 1 E/.t<v 1 ! Address <br /> Phone <br /> Contractor, Z. Address 5 W �� t�YLicense No. a Phone 9d j <br /> TYPE OF WELL/PUMP: ;I NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I DISPOSAL FLD. PROP..LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy f Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta j Depth of Grout Seal Type of Grout <br /> ❑ irrigation _-. Approx. Depth ❑ Easternr Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material(top 501 <br /> Depth Filler Material f Below 5131 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No <br /> _�eptiC system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residencev:n�__ Commercial- _ Other• -- - <br /> Number of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK X Type/Mfg t e Capacity Q No. Compartments <br /> 1PKG. TREATMENT PLT. ❑ Method of.Disposa! <br /> Qistance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest:'. Well _Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size 4 Number <br /> SUMPS ❑ Distance to nearest: Well i € Foundation Property Line �. <br /> QISPOSAL PONDS ❑ 1) x <br /> 4 <br /> 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: I - w <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,I shalt employ persons subject to workman's compensa- <br /> tisof Calif ornia."rte li E <br /> The applica ust�aa�llfor requi d ins tions Co late drawing on reverse <br /> Signe I !e: (} l Date: �1 <br /> + FOR DEPARTMENT USE ONLY <br /> Y <br /> _._ . .�.. .� - w. _. Area <br /> Application Accepted by Date <br /> ,ii <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> j; <br /> Additional Comments: <br />—0- ❑ Manteca--8237104- 8 Tracy-835-6385�� <br /> Applicant- Return all copies to:evironmental-Wealth Permit/Services'1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> * <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO C H y <br /> + EH 1324(REV.s/a s) 97-7d <br /> 7„/_ <br /> EH 1428 �] � <br />