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• APPLICATION FOR PERMIT �. <br /> y SAN JOAQUIN LOCAL HEALTH DISTRICT + <br /> 1601 E. HAZELTON AVE., STOCKTON, CA RPAYMENr <br /> ECEIVED <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in,Triplicate) AUG 11988 <br /> Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install tm r described. This application is <br /> made in compliarice with San Joaquin County Ordinance No 549 for sewage or No.,1862 for well/pump and t� j n n Joaquin <br /> Local:Health District = pEIT'S <br /> EPw <br /> L <br /> Job Address � r � § City �reTary Lot Size PM <br /> Owner's Name Address ��/ .i���/� ' <br /> /t. - Phone <br /> I <br /> Contractor 05 Address Aela*dal- ense No, a i��J� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONS <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 - d <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 6\ <br /> M Public F Other ❑ Delta Depth of Grout Seal �� Type of Grout roc `l 0ti <br /> I I irrigation --Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Desifuction ® Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I'] EPAIR/tkl]DITION 13 OLSTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) ` <br /> 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 /> Distance to nearest: Well FoundationProperty Line q <br /> LEACHING LINE ❑ No. & Length of lines Total length/size �t <br /> s <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS E] Distance to nearest: Well Foundation Property Line <br /> DISPOSAL 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,-state taws, and *--at <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the fotlowin i <br /> g g g: "! certify that in the performance of the work for which this permit is issued, I shall not l <br /> employ any person in such manner as to become subject to workman's compensation taws 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." <br /> The applicant st call for all required inspections. Complete drawing on reverse 'de. , <br /> Signed X 1 file: Date: <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by t7 , _ Date Area 0 C, <br /> Pit or Grout Inspection by _ Date Final Inspection by Date r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 If Tracy 835-6385 � c � <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH13"241REV.1ia51 •� <br /> EH 14-29 ✓ r <br />