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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.—J ON 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. 18622 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District(. <br /> Job Address r' i City Lot Size / rPM <br /> k E <br /> Owner's Name Address 0—"l Phone 117, 7Z <br /> 01 <br /> j f <br /> Contractor ren ' Fs � icense hlaJ Phan, /•/�J <br /> ® ' <br /> s <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ l <br /> € PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I 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 ❑ Delta Depth of Grout Seal Type of Grout <br /> { <br /> D Irrigation ---Approx.' Depth # ❑ Eastern Surface Seal.lnstalled by <br /> Repair Work Done <br /> p i❑ Type of Pump € H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 . <br /> Depth Filler Material {Belo ') <br /> TYPE OF SEPTIC WORK: NEW INSTALLP�.TION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> �// available within 200 feet.) �� <br /> Installation will serve: R sidence_ Commercial_,Pther r i <br /> Number of living units: Number of 49drooms �- <br /> Character of soil to a depth iof 3 feet: ? Water table depth%4 <br /> SEPTIC TANK ❑ Type/Mfg-- Capacity 7 No. Compartments <br /> i <br /> PKG. TREATMENT PLT. 11i4 _ Method of Disposal ( ' <br /> I Distance to nearest: f Well FoundafioM Property Line /� I <br /> LEACHING LINE ❑ No. & Length of lines 0 _ Tgtal length/size <br /> FILTER BED ❑ Distance to nearest: t Well CCZ -,Foundations Property Line ` £ <br /> GE PITS ❑ Depthm y it <br /> ize w Number <br /> SUMPS ❑ Distance to nearest: ; well Foundation.-el Property Line 1 <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 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 penton in such manner as to become subject to workman's compensation laws of-C ilifotnia." Contractor '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." I <br /> The applican st }a for I req a spections. Comp/ drawing averse side. <br /> i <br /> Signed ! Title, Date: <br /> FOR DEPARTMENT USE iONLY /! / <br /> // d / <br /> Applic n Accepted by Date Area <br /> �1 <br /> Grout It l snipe tion by : M1 <br /> � Di Inspection by r�i� <br /> Additional Comments: <br /> ❑ Stk 466-6781 - ❑ Lodi 369-3621 D Manteca BM-7104 ❑ Tracy 8351-6385 <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> E : <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-241REV.t/855 '�' ��.����'] i � o <br /> EH 1428 / <br /> , <br />