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APPLICATION FOR PERMIT { <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED C <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. 11362 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> I. <br /> Jab Address l <br /> CityWLot Size PM j <br /> ii <br /> Owner's Name <br /> `Address " Phone r�g'0 <br /> � f,�► �'[� / <br /> Contractor - <br /> Address ' ' r. / F License`N �3�(3 Phone�/106 fF3� I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ {SYSTEM REPAIR ❑ OTHER ❑ j <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 y- Dia. of Well Excavatio Dia: of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack fl Tracy Type of Casing Specifications <br /> * Public {_l Other f 1 Delta Depth of Grout Sear- r Type of Giaut f <br /> I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by_ 4 <br /> Repair Work Done ❑ Type of Pump H,P. State Work•Done <br /> Well Destruction ❑ Well Diameter Sealing Material )top 50 <br /> Depth Filler Material (Below 501} y <br /> TYPEbF.SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is <br /> ;w available within 200 feet.) <br /> Installation will serve: Residence w� Commercial'" Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:.'"` caWater table depth°° ��"� "" ' 9 <br /> f j 4V {� <br /> ' SEPTIC TANK Type/Mfg Capacity J �� No. Compartments " 'f <br /> ,. PKG. TREATMENT PLT. ❑ Method of Disposal <br /> % +- - Distance to nearest: Well ~ Foundation Property Line <br /> r LEACHING LINE No. & Length of lines` C?0. Total length/size _ +� <br /> FILTER BED ❑ Distance to nearest: Well Foundation–/0 Property Line <br /> SEEPAGE_PITS Depth � �� _. Size Number # f <br /> t � Property <br /> SUMPS L) Distance to nearest: "# -Well h Foundation Pro ert Line <br /> DISPOSAL PONDS O2.4 <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 /> —ules and regutations`of,the San Joaquin Local Health.Di§trict. ; <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 /> N-x <br /> employ any person'in'such manna 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 /> ,.., uon laws of California." <br /> 'The applicant must call for II equired 'osipections. Complete drawing on rev rse side. <br /> Signed X r Title: _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ~� _ Area <br /> F _ Fate Final Inspection by Date <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi.y 369 ❑Y Manteca 823-7104'` lj Zracy 835-6385 p <br /> Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 9'4 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM IT'NO. <br /> INFO CASH <br /> r,EH 13-24(REV.I 5) <br /> EH 14-26 <br />