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poi <br /> APPLICATION FOR PERMIT — of <br /> SAN JOAQUIN LOCAL HEALTH 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 /> 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. (�u� 7- <br /> Job Address 163f V r" r / \O/9 City <Oy'YLot Size PM <br /> Owner's Nam `°/ Mr��I��=AC TrJ,C'!�✓ dss "�� M^ Phone <br /> f <br /> / ContracfJo <br /> r � n � sAddress L = License No. �� Phone _3�Z/C9 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ \ <br /> PUMP INSTALLATION r� SYSTEM REPAIR ❑ OTHER i <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 <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _ Type of Grout <br /> El irrigation 1 J�pprox. Depth ❑ Eastern Surface Seal Installed by /9 r`..� <br /> Repair Work Done Ik0 Type of Pump h, ' -' H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') All <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 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 Number <br /> SUMPS ❑ 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 laws, and <br /> rules and regulations of the San Joaquin Local Health District. <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 appli st c II r al required inspections. Complete drawing on rev rse side. AlSigned 'f��� Title: �C„ <br /> M C 11 d—T V Date: <br /> 72,// <br /> FOR DEPARTMENT USE ONLY L� <br /> Application Accepted by �o Cf1% ,4— Date 1 y Area 6L k <br /> Pit or Grout Inspection by Date Final Inspection by u,�a mate "� <br /> Additional Comments: <br /> 1' Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 Ll Tracy 835-6385 <br /> �`NRlicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P O. Box 2009, Stk., CA 95201 <br /> V !_1 FEE AMOUNT DUE AMOUNT REMITTED CK 4 RECEIVED BY DATE PERMIT NO. <br /> NFO CASH <br /> + EH13-24 1REV.1/8 51 � sgL 5— S5—_7 <br /> � <br /> EH 14-26 <br />