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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1609 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 b I5a <br /> i <br /> Job Address <br /> City LO Lot Size PM <br /> Owner's Name F701f7rJAddress d�5 s <br /> �/� ',,, �� Phone <br /> Contractor's Name ac �,Id y- C. License No. 1 S- <br /> TYPE OF WELL/PUMP: Phone <br /> :Ip NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> ` DISPOSAL FLQ, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ O <br /> El Industrial pen Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Wel! Casing <br /> I ❑ Domestic/Private El Gravel Pack C1 Tracy Type of Casing <br /> i ❑ Public ❑ Specifications <br /> Depth of Grout Seal f �� Type of Grout <br /> EJ Irrigation Other ❑ Delta 5D �hApprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Typeiof Pump H,P <br /> Well Destruction ❑ Well6ameter Ste- State Work ane <br /> //�� Sealing Material (top 50') , ton j <br /> rYkX)1'�y IA"(3)epth Filler Material (Below 501) <br /> TYPE OF SE IC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Resid Ince_ Commercial available within 200 feet.) <br /> f Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ II <br /> Method of Disposal <br /> * Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> ,I. Property Line <br /> SEEPAGE PITS„ ❑ Depth Size <br /> SUMPS Number <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 11 <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 las, and <br /> rules and regulations of the San"Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following; 1 certify pence hich this p t J <br /> employ any person in such manner as to become subject to workman's ccompensation laws oof California."Contractor'se work for hiring or sub-coht act nglsignalturre I <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 las of California." <br /> The applicant must call for all required inspections. Complete drawing onreverse-side. <br /> Signed 1 'IT !elU/C! Title: ►/ ftr06C61Wdt Date: <br /> I� R P MENT USE ONLY <br /> Application Accepted by ` <br /> T _ Date � � ea <br /> Pit or.Grout Inspe by i DateFinal inspect <br /> ion by Date!C <br /> Additional Commen f <br /> ❑ Stk 46&6781 Lodi 3M-3621 Manteca 823-7104 ❑ Tracy 835-6385 I <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i <br /> I� <br /> FEE AMOUNT. AMOUNT REMiTTEp <br /> INFO CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24 ER 14261REV.101831 I� �� f I <br /> o Q . q I a�j�IS q <br />