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APPLICATION FOR PERMIT <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I 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 /> Locaa'll H.e.alth Distract. _ ¢ <br /> .1 <br /> k Job A-Zress <br /> I City Lot Size PM QO/-lC/0-0/ <br /> - e !Phone Owner's Name Yl1117� � (�J Addross Of7tD� �Q[' Q11onContractor �S Address S�� !"r license No. �C/d�� <br /> TYPE OF WELL/PUMP: VNEW WELL, WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 7�='7'- SEWER LINES DISPOSAL FLD.70-64-PROP. LINE <br /> *- FOUNDATION - -----_-AGRICULTURE.-WELL._- —.OTHER.WELL O -PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r! (� <br /> 11 Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing ' <br /> ❑ Domestic/Private )I Gravel Pack ❑ Tracy Type of Casing Specifications <br /> l"I Public f 1 Other 17 Delta Depth of Grout Seal ! Type of Grout_!� <br /> J^' Irrigation --Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done, <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 _ I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I 1 INo 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 \\j <br /> SEEPAGE PITS I I Depth I Size Number <br /> SUMPST_ _ LIDistance to nearest: Well. Foundation. Property Line <br /> DISPOSAL PONDS ❑ i� •—_-�_ �- .. �_--„� <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 DRarict. <br /> Home owner or licensed agent's signature certifies the following: 1 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." t <br /> The applic ust call for all requiM inspections. Complete drawing on reverse side. �/ <br /> Signed X - Title: [ Date: <br /> FOR DEPARTA,10T USE ONLY <br /> Application Accepted by Datep i v c / <br /> f ! Are. <br /> Pit or Grout Inspection by Final Inspection by �JT�C� � Date I <br /> r C - , .� !J J <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Cl Tracy 835-638 'E h h'_6 f'1'7 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE i <br /> INFO AMOUNT DUE MOUNT REMITTED RECEIVED BY DATE PERMIT'ND. <br /> CASF1 <br /> �.EH1 -241REV.FiHs Gov j2-,/0 <br /> EH 14�2e ! <br /> C <br />