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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 i <br /> Local Health District` ,J. 2 /� _ <br /> Job Address <br /> sJ F .S C� y City�to C'�'.+04 Lot Size 0 ey "9 PM <br /> 1 1 , ry a z <br /> 1 <br /> Owner's Name 1 ,9LX)A1[ c4 0ell h Address' U hone 7a <br /> Contractor Address License No. Phone <br /> a <br /> TYPE OF WELL/PUMP:.. .._..'NEW WELL 0 - WELL 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 CONStRUC3J499 SPECIFICATIONS <br /> ❑ Industrial ❑ open Bottom ❑ Manteca Dia. o ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack -3 Tracy ype of Casing Specifications <br /> 1"1 Public ❑ Other + {-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth I stern Surface+Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P: State Work Done <br /> Well Destruction ❑ Well Diameter Sealing-Material (top 501 <br /> Depth Filler Material (Below 50') 5^ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION LI DESTRUCTION (No septic system permitted if public sewer is vt <br /> available within 200 feet.) <br /> Installation will serve: Residence "_ •Corhmercial—_'-­ 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 /> ,s <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 w ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size — _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Lbcal 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,.) 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 must call for all re wired inspections. Complete drawing on reverse side. 4 <br /> Signed X Title: h Q 9 Date/49 T e2 9- <br /> ~ <br /> _. FOR DEPARTMENT USE.ONLY . { <br /> Application Accepted by Date fArea <br /> Pit or Grout Inspection by to Final Inspection by ate <br /> I <br /> Additional <br /> Comments- <br /> Ll Stk 466-6781 ❑ odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <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 RECEIVED BY DATE PERMIT NO. <br /> INFO - <br /> -+ EH 13-24 EH 14-2gIREV.i�ei51 �. �..�� �� g— V7 <br /> —!Iq <br /> S <br />