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APPLICATION FOR PERMIT i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 SCONE <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 /> ��7 e <br /> Job Addres /'f' Ci [QUI' Lot Size PM <br /> Owner's Name n Address •Z Phone <br /> Contractor�`-� �'�� Address 1- 8 �'�� - // 2 36 'J 4 3� <br /> License NoG� 3�� Phone_ <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ?1' SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE g <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE ? TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing <br /> 6y'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications' <br /> r Publicfp _•_4 a C1 Other ? ❑ Delta Depth of Grout Seal Type of Grout _ <br /> 1 1 Irrigation =.-. P, �.Approx. Dept 17 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pumper H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I] REPAIR/ADDITION LI DESTRUCTION l I (No septic system permitted if public sewer is <br /> $, available within 200 feet.) <br /> Installation will serve: Residence `Commercial"_°`rOther'"' '* �• y--- -- <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a depth of 3 feet: Water table depth w <br /> SEPTIC TANK ❑ Type/Mfg Capacity " No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of.Disposal <br /> Distance'to nearest: Well Foundation Property Line <br /> F <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 Joaqdin 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, Ishall 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 applican st c II for all equ'ed inspecti ns. Complete drawing on r arse side. <br /> Signed � // 7 �7'z' <br /> 9 �"Fftte: Date: !_�_ /F <br /> FOR DEPARTMENT USE ONLY trftf �� <br /> Application Accepted by V2 Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 F) Tracy 835.6385 <br /> vim— <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> i, <br /> ♦,EH 13-24 IREV. /n 51 ��^ C9Gj ^ __�� �,a "')—��j <br />