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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 21579 S. Union i;ian'Eece, <br /> City Lot Size PM <br /> J'oe Yeyers wale <br /> Owner's Name Address Phone _ <br /> Contractor's Name -Doug Wzlaon F u ps License No. a 64921 Phone <br /> 856 -2' 87 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION -XI SYSTEM REPAIR ❑ OTHER ❑ <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 Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta: Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by t j <br /> Repair Work Done ❑ Type-of Pumpj H.P:. State Work`Done <br /> Well Destruction ❑ Well-Diameters Sealing Material (top 50') <br /> f <br /> Depth � Filler Material (Below 501 J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is S <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial,_;Other. f kA <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of'3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ a Method of Disposal p� <br /> Distance to nearest: Well. 1 r. Foundation . Property Line <br /> LEACHING.LINE ❑ No. & Length of lines, _- Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS Depth Size —. Number <br /> SUMPS ❑ 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 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 such manner 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 /> tion laws of California." <br /> The applicant m - all for all equirfed in�pecpons Complete drawing on ieverse side1. <br /> . <br /> Signed)�_ ��// r / Title: � 1�(�f '�'` Date: �� <br /> FOR DEPARTMENT USE ONLY i G f <br /> Application Accepted by Date v ` �i Area / 3 <br /> Pit or Grout Inspection by Al 16 Date Final Inspection by OL,9-- - Date.] -h <br /> Additional Comments: I <br /> ❑ Stk 466-67$1 ❑ Lodi 369-3621 Manteca 823-7104 LJTracy 835-6305 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE ' AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'N0. <br /> -+ <br /> r <br /> EH 13-24(REV.10183/ `�`7 <br /> C Z <br /> O <br /> iFH 14-26w -S. C7 /� S 1 <br />