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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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 Rule R lati s t <br /> Local Health District. Joaquin <br /> Job Address s9 9 f <br /> City /1U A Lot Size PM <br /> Owner's Name S A/ E Address <br /> Phone <br /> Contractor A40 46 6U,9eVZb Address .f,. ,¢8F Q�oT- 1L.� <br /> ��- License No. ZS�Y7b Phone A1,73TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC,TANK OTHER ElSEWER LINES �_� DISPOSAL FLD. PROP. LINEVi <br /> FOUNDATION AGRICULTURE WELL <br /> • OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- <br /> Industrial ff Open Bottom (5 Manteca <br /> Oia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy � _ <br /> 1-1 Public y'` Type of Casing Specifications <br /> ❑ Other 11 Delta ... Depth of Grout Seal ' <br /> I I Irrigation Approx."Depth I I EasternType of Grout <br /> Repair Work Done ❑ Type of pump H.PSurface Seal Installed by <br /> , i <br /> State Work pone <br /> Well Destruction F-1WellDiameter <br /> Sealing Material ftop 50'} <br /> - Depth Filler Material (Below 50'} ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LI DESTRUCTION I] lNo septic system permitted if-public sewer if <br /> Installation will serve: Residence Commercial available within 200 feet.} <br /> Is <br /> Other _ � <br /> Number of living units: -1_ Number of bedrooms <br /> Character of soil to a depthpf 3 feet: <br /> SEPTIC TANK Type/Mfg �Lf� -- /per Water table depth <br /> PKG. TREATMENT PLT, [I �� — Capacity Z D No. Compartments Z <br /> Distance to nearest: WellJ* i " Method of Disposal <br /> Foundation �_�� Property Line <br /> LEACHING LINE 1V No. & Length of lines ` r <br /> FILTER BED " Total length/size IO.:X L r <br /> ❑ 'Distance to nearest: Well Foundation <br /> Property LineQ�� I <br /> SEEPAGE PITS <br /> (1:i' Depth <br /> Size Number r <br /> SUMPS L] Distance to nearest: Well - -, <br /> b1SPO$AL PONDS ❑ Foundation Property Line' <br /> I hereby certify that f have prepared this"application and thatthe work will be done in accordance with San Jgaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin-Local Health District. y <br /> s signature certifies the following': "I certify that in the performance of the work for which this permit is issued, I shalt not <br /> Home owner or licensed agent' <br /> employ°any person in such manner'as to become subject to.Workman's compensation laws of California."Contractors hiring or sub contracting signature <br /> certifies the following: "1 certify that tri the performance of the work for which this permit is issued,.!shall employ persons subject to workman's compensa- <br /> tion laws of California." � s� _ � <br /> The applicant must call for"all re uiredrins,$ �' <br /> q pections ,COmpfete dravying on'roerse side. <br /> Signed X <br /> Title- <br /> n ' ate: <br /> r <br /> DEPARTMENT USE ONLY — <br /> ;�. <br /> Application Accepted by ,Q 3� <br /> '� Date Area <br /> Pit or Grout Inspection by' { <br /> -Date Final Inspection by Date <br /> Additional Comments: r' �° .,, -' ' <br /> Date ! <br /> Stk 466-6781 ❑'Lodi 369-3621 ❑ Manteca .823-7104" f <br /> ❑ Tracy 835-6388 <br /> 4plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT.DUE <br /> INFO AMOUNT REMITTED <br /> n .!RECEIVED BY DATE j]PERMIVN0j ;I <br /> + EH 13-26(REV.1iH51 e 0 �O <br /> EN 11-Ze r ' C)s n <br />