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V - APPLICATION FOR PERMIT j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' 1601 E. HAZELTON AVE., STOCKTON, CA <br /> I Telephone {209} 466-6781 t �� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED "� A <br /> �r <br /> (Complete in.Triplicate) w _ > <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 /> X1_.1" ask <br /> ,,.. ff w tw ar i <br /> Job Address l�[! 0L,/�TQ�iI/ y D Q <br /> City Lot Size .PM <br /> XL=Cki�! x <br /> Owner's Name �`_ Address l c� � Phone 7 7 7 <br /> Contractor O w Address <br />� License No. Phone <br /> TYPE OF WELLlPUMP: NEW WELL LlWELL 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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ DeltaDepth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br />` Repair Work Done ❑ Type of PUMP H.P. {N� <br /> State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing"Mateial {tap 50'1 w <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑1 DESTRUCTIO mo septic system permitted if public sewer is <br /> Jk vailable within 200 feet.► <br /> Installation will serve: Residence Commercial Other _ <br /> :. <br /> Number of living units: Numbtetr of bedrooms <br /> Character of soil to a depth of 3 feet: 1 Water table depth <br /> SEPTIC TANKType/Mfg. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ s Method of Disposal <br /> Distance t nearest: Well -Foundation Property'Line. <br /> I a <br /> LEACHING LINE ❑ No. & Length of lines , <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line h i <br /> SEEPAGE PITS ❑ Depth I Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation �F rope`rty Line r <br /> DISPOSAL PONDS ❑ y <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. <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."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." <br /> The applicant st call for all re it ins pe tions. Complete drawing on reverse side. <br /> k Signed X _ Title: Date: t7 r r _ <br /> I FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ � <br /> Date Area <br /> Pit or Grout Inspectio Date Final Inspection by DatQc4_ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621. ❑ Manteca 823-7104 ❑ Tracy 835- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009', Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> + EH 13-24(FiEV.I"W d0 <br /> EH 14-M �-'G_! ���I `aZ^ Q , <br />