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<br />APPLICATION FOR PERMIT
<br />SAN JOAQUIN LOCAL HEALTH DISTRICT
<br />1601 E. HAZELTON 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.
<br />LJ
<br />Job Address city d�-71y2uPD -�--
<br />-. Lot Size PM
<br />Owner's Name 12, J ec"I Address - Phone
<br />t `Contractor le _ Address 2 cp. j � {�, } -License No Phone
<br />TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DE$TRUCTIO
<br />F, Irrigation ---Approx. Depth ❑,Eastem Surface Seat Installed by—
<br />Repair Work Done r Type of Pump+-�'-"rp Jam.
<br />— _ State Work Done
<br />Well Destruction ❑ Well Diameter _-_ _ Sealing Material flop 50'1 w 1
<br />F
<br />Depth Filler Material (Below 50'){.
<br />TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION DESTRUCTION ❑ (No septic ;;s""�` �' available within
<br />Installation will serve: Residence commercial Other _
<br />Number of living units: Number of bedrooms _ 2
<br />r
<br />A /
<br />ermitted if public sewer is
<br />feet.) ' NJ
<br />Character of Boit to a depth of .3 feet: ' Sly Qii°}jV[ Water table` depth _
<br />SEPTIC TANK C Type/Mfg gj3pacity No. Compapriments
<br />PKG. TREATMENT PLT. G = _
<br />j' Method of Disposal
<br />Distance to nearest: Well Foundation _ Property Line
<br />.ALEACHING LINE , . iNo. & Length,of lines —_a � *� � �% .Total length/size_�C
<br />FILTER BED L1 Distance to nearest: 'WellFoundationA'„Z3 /C�,
<br />e3
<br />Q_ Property Line 0 ,�r
<br />,p SEEPAGE PITS ❑ Depth ,Size _ _ Number
<br />* 1
<br />}'a SUMPS ❑ Distance to nearest: well — foundation Property. Line .
<br />i DISPOSAL PONDS ❑ 7 , -4 N
<br />hereby certify that I have prepared this application anc�that the work will be douse in accordance with San Joaquin county ordinances, state laws, and
<br />r ,rules and regulations of the San Joaquin Local Health ISiitrict. y, "_701,
<br />Home owner or licensed agent's signature certifies the following: " 1 certify thatin_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' iv rki an's compensation 1aws.of_Califomia,:�Contractor s hiring.or sub -contracting signature
<br />Certifies the following: "I certify that in the performance of the work for which thispeirmit is issued, I shall einploy•persons subject to workman's compensa-
<br />tion laws of California."
<br />The applicant must call for Ireguired inspections. Complete drawing oneversa side.
<br />Signed Tit
<br />• � N i aA
<br />FOR P T USE ONLY
<br />t
<br />Application Accepted by Date Area' /
<br />Pit or Grout Inspection by - ! ; Date Final Inspection by Date
<br />f Additional Comments: ` :1 N1. ' +
<br />❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6,486
<br />'Applicant - Return all copies to: Environmental Heahh Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201
<br />kill
<br />+ EM 1324 {REV. 1/ 8 5.
<br />EH 1428
<br />INFO .FEE-AMOUNTpUE
<br />PUMP INSTALLATION E SYSTEM REPAIR J
<br />N❑
<br />OTHER ❑
<br />DISTANCE TO NEAREST:_SEP_T-I,C,TANK
<br />_
<br />SEWER LINES _DISPOSAL FLD._
<br />PROP. LINE
<br />t FOUNDATION
<br />_ AGRICULTURE WELL _ OTHER WELL
<br />PITS/SUMPS _
<br />INTENDED USE
<br />I TYPE OF WELL
<br />ti--�❑
<br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br />❑ Industrial
<br />Open Bottom
<br />FT Manteca Dia. of Well Excavation
<br />Dia. of Well Casing
<br />❑ Domestic/Private
<br />I-1GravelPack
<br />❑Tracy Type of Casing
<br />Specifications
<br />'.❑ Public
<br />L Other
<br />❑ Delta Depth of Grout Seal
<br />""'Type of Grout—
<br />F, Irrigation ---Approx. Depth ❑,Eastem Surface Seat Installed by—
<br />Repair Work Done r Type of Pump+-�'-"rp Jam.
<br />— _ State Work Done
<br />Well Destruction ❑ Well Diameter _-_ _ Sealing Material flop 50'1 w 1
<br />F
<br />Depth Filler Material (Below 50'){.
<br />TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIR/ADDITION DESTRUCTION ❑ (No septic ;;s""�` �' available within
<br />Installation will serve: Residence commercial Other _
<br />Number of living units: Number of bedrooms _ 2
<br />r
<br />A /
<br />ermitted if public sewer is
<br />feet.) ' NJ
<br />Character of Boit to a depth of .3 feet: ' Sly Qii°}jV[ Water table` depth _
<br />SEPTIC TANK C Type/Mfg gj3pacity No. Compapriments
<br />PKG. TREATMENT PLT. G = _
<br />j' Method of Disposal
<br />Distance to nearest: Well Foundation _ Property Line
<br />.ALEACHING LINE , . iNo. & Length,of lines —_a � *� � �% .Total length/size_�C
<br />FILTER BED L1 Distance to nearest: 'WellFoundationA'„Z3 /C�,
<br />e3
<br />Q_ Property Line 0 ,�r
<br />,p SEEPAGE PITS ❑ Depth ,Size _ _ Number
<br />* 1
<br />}'a SUMPS ❑ Distance to nearest: well — foundation Property. Line .
<br />i DISPOSAL PONDS ❑ 7 , -4 N
<br />hereby certify that I have prepared this application anc�that the work will be douse in accordance with San Joaquin county ordinances, state laws, and
<br />r ,rules and regulations of the San Joaquin Local Health ISiitrict. y, "_701,
<br />Home owner or licensed agent's signature certifies the following: " 1 certify thatin_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' iv rki an's compensation 1aws.of_Califomia,:�Contractor s hiring.or sub -contracting signature
<br />Certifies the following: "I certify that in the performance of the work for which thispeirmit is issued, I shall einploy•persons subject to workman's compensa-
<br />tion laws of California."
<br />The applicant must call for Ireguired inspections. Complete drawing oneversa side.
<br />Signed Tit
<br />• � N i aA
<br />FOR P T USE ONLY
<br />t
<br />Application Accepted by Date Area' /
<br />Pit or Grout Inspection by - ! ; Date Final Inspection by Date
<br />f Additional Comments: ` :1 N1. ' +
<br />❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6,486
<br />'Applicant - Return all copies to: Environmental Heahh Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201
<br />kill
<br />+ EM 1324 {REV. 1/ 8 5.
<br />EH 1428
<br />INFO .FEE-AMOUNTpUE
<br />`� ICENbUNT REMf�TE
<br />m ASH~
<br />REc
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