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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 /> ic <br /> Job Address jr 2-9 L.,/L- �� %f-%/�d <br /> d� City Lot Size PM <br /> Owner's Name (, ��a1L� �/G d2� Address S Phone I a3^Jd <br /> Contractor A4H J0"J Address <br /> License`No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 /> M Public 17:1 Other 17 Delta Depth of Grout Seal Type of Grout _ <br /> I i Irrigation _-.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done , 1 <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 _v+ <br /> Depth Filler Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR 1ADDiTION DESTRUCTION I I (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 soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE >( No. & Length of lines J 4:20 z u Total length/size <br /> FILTER BED ❑ Distance to nearest: Well �c-VO - Foundation M" Property Line <br /> �I 1 <br /> SEEPAGE PITS Depth oZ� Size 91 1�Zz Number <br /> SUMPS C7 Distance to nearest: Well /001 Foundation fe9, Property Line -/Of <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 DiMrict. <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." Contractors luring 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 ust call for all required inspections. Complete drawing on reverse side. l <br /> Signed X Title: Date: I[ e,4p <br /> EPARTMENT USE ONLY, <br /> Application Accepted by Date <br /> Area <br /> (/J <br /> Pit or Grout Inspection by5 Da 1 Final Inspection by ' Date fCK <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <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 CASH RECEIVED BY DATE PERMIT-NO. <br /> + EH 13-28 IREY.i/H 51 <br /> EH 1 �0. GJ 1I7bZ L <br /> A-26 <br />