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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 <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 /> I ,r!�� Q 4� Ci Lot Size 7a �S PM <br /> Job Address �J <br /> hone 5 <br /> Owner's N e <br /> Address[P <br /> Phane <br /> I <br /> . <br /> � '. L Icense N0. T <br /> Contract Addr _ <br /> ess <br /> TYPE OF WELL/PUMP: I` NEW WELL ❑ ..,,WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REP OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP_ LINE <br /> FOf9NpATION AGRICULTU ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS <br /> I ❑ Industrial ❑ Open Bottom ❑ eca Dia. of Well Excavation Dia. of Well Casing <br /> I' Type of Casin Specifications <br /> ❑ pomestic/Private ❑ Gravel Pack Tracy g <br /> h Public <br /> P ther Ll pelta Depth of Grout Sea{ Type of Grout----- <br /> 0 <br />' I I lrrigation # �� prox. Depth i I Eastern Surface Seal Installed by - <br /> I __H- - -�-•----State'Work Done_ <br /> Repair Work Done ❑ ype of PumpP <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 V <br /> 1' pepth Filler Material (Below 501 _ <br /> rS <br /> TYPE OF SEPTIC WORl l DESTRUCTION l I INo septic system permitted it public sewer is <br /> K: NEW INSTALLATION 1.1 REPAIR/ADDITION <br /> III, L available within 200 feet.) <br /> Installation will serve: Residences Commercial_ Other <br /> i Number of living units: Number of bedrooms' <br /> YWater table depth D <br /> Character of soil to a depth F f 3 feet: <br /> SEPTIC TANK i thType/Mfg Capacity QQ No. Compartments Z— <br /> ' TREATMENT PLT. ❑ Method of Disposal <br /> 'Distance to nearest: Foundations Property Line 5 <br /> I <br /> 4. o Total len th/size <br /> LEACHING LINE W—I.No. & Length of lines r� g <br /> 1 FILTER BED ❑ i:�pistance to nearest: Well 11� Foundation 0 Property Line <br /> � SEEPAGE PITS 11 .Depth 1,04t Size hy <br /> Number <br /> j SUMPS Distance to nearest: Well Foundation Property Line <br /> I'. <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 Local Health Di§trict. T <br /> Horne 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 person in suchmanner 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 compansa- <br /> tion laws of California." 9dlili f <br /> The applicant must Il for all required inspections. Complete drawing on reverse side. <br /> Ir Signed X L Title: Date: Ion�15C <br /> FOR DEPARTMENT USE ONLY <br /> 21 t Application Accepted by "I pate Area <br /> Pit or Grout Inspection by II Date Final Inspection by "M _ Date <br /> ` Additional Comments: <br /> q <br /> f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies lo: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I� <br /> r FEE AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE tRMIT NO <br /> INFO :yp' <br /> t ♦,EH 13-24 IREV.i/n bl -70 �` <br /> EH 14-2a 13 <br />