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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 /> Job Address City Lot Size :2,t ')C 12 q` <br /> PM <br /> �tJ �L7(� Ca <br /> Owner's Name T" Address Phone <br /> e- <br /> r� E 3 <br /> Contracto-laT) ) 1-�'1�&QW6LL- Address 12 z5l, - AC-TL) License No. Phon 91W -G i <br /> TYPE OF WELL/PUMP: i� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER`X <br /> s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL- <br /> .11. <br /> ELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications le-1944b)/4k)L-I <br /> ❑ Public ❑ Other ❑ Delta Depth-of Grout Seal Type of GroutlW &A <br /> CK <br /> ❑ Irrigation L11-Approx. Depth ❑ Eastern 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 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 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: �N Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ i Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ I 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 Local Health District. <br /> Home owner or licensed ageAt'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 such manner as to become subject to workman's compensation laws of California."Contractors 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." I�. <br /> The applic n must call for allTitle:) r q ire spections. Complete drawing on reverse side. <br /> I <br /> /9Z9 <br /> Signed 1 ate: / 7 <br /> 4-: Q <br /> e FOR DEPAR E T USE ONLY <br /> 1-7 f <br /> } Applic�;n' <br /> AM <br /> Date Area <br /> Pit orut 4 t nal Inspection by <br /> Additional Comments: ' ' '" <br /> IDA <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 racy 8356385 <br /> Applicant- Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. <br /> INFO „ <br /> ., +-EH 13-24(REV.1/5 5) ' '.I S C5O ��f V11 "'�--7 <br /> EH 14-28 _ <br /> SII _ <br />