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APPLICATION FOR PERMIT <br /> AL'4DISTRICT <br /> DISTR <br /> SAN JOAO.UIN LOC i . <br /> 1601 E. HAZE T~ON AVE., STOCKTON, CA <br />"i Telephone (209) 466-6781 <br /> . <br /> PERMIT EXPIRES 1 YEAR FROM DATE 1SSUED <br /> I (Complete in Triplicate) <br />" as .;:.: lL?LrIOj:�;.��,'' application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instal!the work herein described.,• s <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or.No. 1862 for well/Pump and the Roles and Regulations of the San Joaquin <br /> x r+ <br /> i Local Health District, <br /> ♦." °h i. fly-.' , <br /> Lor.,, •"" ,,,,, ` o►- .PM <br /> City P t Size <br /> Jab Address <br /> ,A Phone <br /> r's Name i• . w .. <br /> 1�\C. <br /> Owne "::Address <br /> jAddress �L cense No hone <br /> I Contractor DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: ? NEW WELL ElWELL REPLACEMENT Q <br /> ION ❑ SYSTEM REPAIR ED] OTHER <br /> PUMP INSTALLAT ❑ <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK.-A ! SEWER LINES PITS/SUMPS <br /> FOUNDATI01Vx' _ AGRICU LTU RE"WELL OTHER WELL <br /> r r <br /> INTENDED USE TYPE OF WELL 1 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom: MantecaDaa:.of Wetl Excavation _.,. Specifications <br /> �' — ❑ Tracy � N�Type of Casing s <br /> ❑ Domestic/Private ❑ Gravel Pack tjt., l ; _ Type of Grout <br /> ❑ Public f "' Q Other I ❑ Delta Depth of Grout Seal <br /> -!--Approx. ep : ❑DthEastern " Surface Seal Installed by ) G <br /> ❑ Irrigation i State Work Done <br /> I Repair Work Done ❑ Type of Pump H P ' I �� <br /> s?. 1r Sealing Material (top 50'i "- <br /> Well Destruction ❑ Well diameter ,, <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLyATIOfN,❑ REPAIR/ADDITION �BE`STRUCTION Q "availabpe�with within200 feet;) if public sewer is <br /> Installation will serve: Residence SOS vLi I <br /> ercial_ ther N <br /> Number of living units6--I— Number of-bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ I Type/Mfg Capacity <br /> �� Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> s i Distance to nearest: Well „ Foundation Property Line o <br /> Total ierigth/size <br /> LEACHING LINE x j & Leigth of fines <br /> i r d Foundation' ' Property Line <br /> i FILTER BED ❑ Distance to nearest: !�?II" <br /> ' Size Number <br /> 6 SEEPAGE PITS 11j 10rpth <br /> SUMPS ❑ Distance to nearest: '$ Well F Foundation Property Line <br /> jj <br /> DISPOSAL PONDS -i ❑t 1 { <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 /> r. <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, 1 shall not <br /> employ any person in such manner as td become subject to workman's'compensation laws of California."Contractors hiring csub-contracting signature <br /> "certifies the follow! b-"I certify that in the-performariife of"the work-for-which this permit is issued I shall employ persons subject to workman's compensa- <br /> ti ws of California. <br /> apple ust call fo all r ired ns cti n Co ete drawing o reverse sid } <br /> Title: 1 , 4 Date: <br /> Signe <br /> --••�•��•--•-- """`FOR DEPARTMENT'USE ONLY '�/ <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by .'Date ZL-( aFinal-inspection by Date i <br /> . <br /> Additional-Comments: <br /> ❑ Stk 466-6781 Q Lodi 369-3621 5-Manteca 8234144 �. ❑ Tracyx"835-63.85 <br /> Applicant-Return all copies to: Environmental Hi=afth Permit/Services 1601 E. Hazelton`Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT`NO. - <br /> INFO <br /> + EH 13-241REV.I B5] <br /> EH 14-26 <br />