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APPLICATION FOR PERMIT �fte <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. l I / / -��/ f <br /> / f �- Q k7 Cityzoo//­ <br /> 0 Lot Sizes[j��•- PM <br /> f- Job Address I-V/l / b <br /> �j(� Phone <br /> mdl'YlAddress 3 <br /> Owner's Name --� 1 I <br /> ,Contractor I blf Ulf -G�' Address P,o - LDC (a LI cense No. Phone <br /> _ TYPE OF WELL/PUMP: NEW WELL 7V•vv WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLnVAGRICULTURE <br /> or SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKEWER LINES ISPOSAL FLD.�.5— PROP. LINES 1 <br /> FOUNDATION WELL OTHER WELL PITS/SUMPS J <br /> INTENDED USE TYP OF PROBLEM AREA CONSTRUCTION , ICATIO �� <br /> ❑ Industrial pen Botttomom ❑ Manteca Dia. of Well ExcavatitioeDia. of Well Casing <br /> Q(Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> nPublic <br /> 71 Other Fl Delta Depth of Grout Seat t;-() Type of Grout – <br /> I•;(Irrigation ­Approx. Depth/I I I EasttP p Surface Seal Installed by - \ <br /> Repair Work Done ❑ Type of Pump it p In 'J'V' H.P. .S State Work Done <br /> d Sealing Material (to 50'1 <br /> Well Destruction ❑ Well Diameter 9 p � <br /> r. Depth - Filter Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I RE IR/ADDITION I I DES UCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet-) <br /> Installation will serve: Residence_ Commercial_ or <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK El Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well F dation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: ell Foundati Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS Ll Distance to ne st: 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 laws, and <br /> rules and regulations of the San Joaquin Local Health D13trict. <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." 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 applicantI required inspections. Complete drawing on reverse side. <br /> Signed < - Title: ✓ �Ad-f- Date: <br /> n^ FOR DEPARTMENT USE ONLY Q Q <br /> Application Accepted by t Date U- `-`� Area <br /> ` Date <br /> Pit or Grout Inspection byDateDate Final ONLY <br /> by <br /> Additional Comments: ," " <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca Servic04 ❑ 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 /> FEE CK RECEIVED BV GATE PERMIT NO. <br /> UNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> �.EH3-24 IRVr/n � `_� <br /> FH 14e cVD 1 /0✓ V � n <br /> � <br /> Oi•/` <br />