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r� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA _ <br /> i Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> pp lcahon rs ere y ma e o e an oaqutn o a ea is nc or pptieatiort is---- <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 tar ell/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 4 O (414,1771- ity;�k_2 0�Lot Size PM <br /> Owner's Name Yom, AddressL <br /> f � Phone <br /> Con tractor�w•.e% Address -2 r7/� _04 ��1eeense No. Phone 7!�-7p Z 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L]; DESTRUCTION [- ' <br /> PUMP INSTALLATION ID SYSTEM REPAIR ❑; OTHER LJ <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 - rteDia. of Well Casing a <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 11 Specifications .� <br /> I l Public fa Other 1-1 Delta Depth of 61 Semi 7. ZY 7-1 Type of Grout r'� , <br /> f I Irrigation __,Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 1.1 Type of Pump H.P. �gg State Work Done _ C) <br /> Wel l derrstruction (] Well Diameter Sealing Material (top 50') <br /> Depth Filler Material 18elow 50') <br /> TYPE OF SEPTIC W RK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installatiorr,witl serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth o 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity 1i No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation L Property Line <br /> I� <br /> LEACHING LINE Ll No. & Length of lines <br /> g Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Site � - <br /> Number <br /> SUMPS f_I 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. I. <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."Contractors 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 applicant must ca or all required ' spectians. Complete drawing on reverse side. <br /> Signed X Title: �n �. Date: S-J�-S`7 <br /> ` I <br /> E USE ONLYI <br /> Application Accepted b Date Area <br /> Pit rou b�100 �� � <br /> tae by Dat Final Inspection by <br /> A itiona Comment <br /> 'I <br /> ❑ Stk 466-6781 ❑ L 1 369- 1 0 Manteca 823-7104 ❑ Tracy 83 <br /> Applicant - Return all copies to: En Ironmental Health Permit/Services 1601 E. Hazelton A P.O. Box 2005, Stk., CA 95201 <br /> I� ( <br /> INFO AMOUNT DUE AMOUNT REMITTED dASAA RECEIVED BY DATE PERMIT'NO. <br /> • EH13-24(REV <br /> .tin <br /> EH 14-26� r <br />