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i <br /> : APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br />` Telephone (209) 466-6781 <br />! <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 /> Job Address � ' ' `leG6101_/Es City Lot Size PM <br /> P Owner's Name y Address ZeO ' �""��f�p� - -- Phone o <br /> Contractor f7 Address License No. � Vo Phone <br /> TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT _❑ DESTRUCTION <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 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> I <br /> [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public ❑ Other Fl Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation —.-Approx. Depth ( I Eastern Surface Seal Installed by <br /> ! GqF'� <br /> • Repair Work Done Ll Type of Pump H.P. State Work Done Q <br /> Well Destruction Well Diameter. Sealing Material (top 50') o Ck.�"9F <br /> Depth / Filter Material (Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is <br /> f available within 200 feet.) <br /> Installation will serve: Residence `fes Commercial— Other <br /> F <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. ❑ M- e`thod of Disposal <br /> 4 Distance to nearest: Well Foundation Prop'64YLi4 e <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 4 i <br /> " SEEPAGE PITS ( I Depth Size Number <br /> M SUMPS_ ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL'PONDS,_ ❑ / <br /> I hereby certify that'(`have1fir Dared this application.and that the work will be done in accordancewwith,San.Joaquin county ordinances, state laws, and <br /> rules and regulations-of-the San Joaquin Local"Health-District. <br /> Home owner or licensed ageriVa 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 mannVr_as4.o become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> fff certifies the following: "I certify that in the�pe�rformance of the work for which this ermit is issued,1 shall employ..persons.subjectso.workman's compensa- <br /> tion laws of California." ! <br /> The,applicant r rec!I tions. Complete drawing on reverse s' e. <br /> eZ <br /> Signed X Title: Date: <br /> v� <br /> I FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 04tedw <br /> V <br /> Pit or Grout Inspection by e ,!Final Inspection by _ ,- r D�to d rq <br /> Additional Comments: <br /> `er� Z 6 ` ! <br /> E ❑ Stk 466-6781,t ❑ LoJi 369-3621 1 ❑ Manteca 823-7104 ❑ Tracy 83 6385 1 <br /> Applicant- Return all copies to: Environmentlit Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ! FEEAMOUNT DUE 1S AMOUN ,REMITTED CASH RECEIVED BY DATE PERMIYNO. <br /> INFO <br /> e ...EH13-24MEV.rik � <br /> 5� /� <br /> " EH 14-2s - _ <br />