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APPLICATION FOR PERMIT <br /> SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 <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 /> Job Address 91.?3 C04nno d City 0cJCX0 N. Lot Size—.60 X 106 <br /> PM` <br /> Owner's Name eie e D)f.5i4 Address _ a 31 C r�nro 7Phone <br /> Contractor � 11�/ood Address 6 : I y License No. ya7s`�` 7 <br /> �_Phone 'S/6S=.3�7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ —OTHER'❑" <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' _ AL.FLD. PROP. LINE «iy <br /> FOUNDATION �AGRICULTURE WE L OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS # <br /> ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private D Gravel Pack r racy Type of Casing Specifications <br /> D Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> - <br /> ❑ Irrigation Ap Depth ❑ Eastern Surface Seal Installed by <br /> I <br /> Repair Work Done ❑ T of Pum t <br /> p p H.P. State Work Done <br /> Well Oestruction Well Diameter Sealing Materialltop 501. <br /> Depth f Filler Material IBelow 501 4 / I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONM DESTRUCTION (No septic system permitted if public sewer is <br /> € available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of sail to a epth of 3 feet: I Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ o Method of Disposal <br /> Distance to nearest: _Well -Foundation---­�"Property-Line•'. <br /> LEACHING LINE' ❑ No. & Length of lines + Total length/size- <br /> FILTER BED D Distance to nearest:' Well �Foundation Property Line <br /> r� <br /> `I <br /> SEEPAGE PITS ❑ Depth � , Size 6 ; �' • � Number <br /> .F , <br /> SUMPS. ❑,.Distance to nearest:r 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, tate laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the followin y pe ` pe <br /> g 9 g: "I certif that in the rformance of the work for which this rmit is issued, I shall not <br /> employ any person in such manner as to become subject-to- eit's compensation laws-of7Califo6a.'4Cbntractor's hiring_or.sub contract Ing signature <br /> certifies[he following "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman compensa- <br /> tion laws of California." <br /> The applicant must call for all required ins ectio s. Complete drawing on reverse side. <br /> Signed X Title: % Date: 'a7 <br /> FOR DEPARTMENT USE ONLY1. <br /> Application Accepted by Date l( 1 Area <br /> Pit or Grout Inspectiony� Date Final Inspection by 1` Date <br /> I <br /> Additional Comments: 1 \.1� ���r- � / iJG.UA�� df fJvj <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 _ ❑ Manteca 823 04 0 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 Vf1 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK 4 <br /> CAPH RECEIVED BY DATE PERMIT'NO.yq <br /> + EH14-24(REV.1/Hs] 35'rQr� <br /> EH 1428 <br /> L1 <br />