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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> 1601 E. HAZE; ION AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED P , <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. 18652 for well/pump and the�Rules and Regulations of the San Joaquin <br /> `' <br /> Local Health District. ' ' -� -" .. <br /> � <br /> Job Address _ [� �' C �. �`.�S f <br /> T— � _ City 4�-fi Lot Sle <br /> ize PM <br /> �. r / <br /> Owner's Name �� C^: 7 d — Address 11� <br /> P_Fione.. .• <br /> Contractor CL.► Address '`n' License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> F <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrialnrbpen i3ottom.. ❑ Manteca Dia. of Well Excavation Dia..of Well Casing I i <br /> El Domestic/Private❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> bl c ❑ Other& ❑ Delta Depth of Grout Seal Type of Grout <br /> Q Irrigation"' _—Approx Dept h ❑ Eastern Surface Seal Installed by , <br /> Repair Work`Done. .© wType=of`Pump H.P. State Work Done <br /> WellDesiructio ❑ Well Diameter.- Sealing Material {top 501 <br /> Depth Filler Material (Below 50') <br /> • TYPE OF SEPTIC WORK: NEW=INSTALLATION ElREPAIR/ADDITION DESTRUCTION Cl (No septic system permitted if public sewer is <br /> E available within 200 feet.) <br /> Installation will serve: Residence Commercial Other s <br /> Number of living units: Number of(bedroomsy <br /> �.. . <br /> Character of soil to a depth of 3 fee Water table depth <br /> SEPTIC TANK ❑ Type/Mfg --,r:W.571AJ&-- –Wool 'Capacity !Z� No. Compartments 2– <br /> PKG. <br /> PKG. TREATMENT PLT. ❑ t <br /> Method of Disposal <br /> DistanPetolhear4s�Welll ZrOw Foundation Property Line '15 <br /> eLEACHING LINE ' "fir g S'. <br /> � No� Length of lines Total length/size � 0 <br /> FILTER BED -6 !an�ce to nearest: - Well Foundation Property Line <br /> c. <br /> •SEEPAGE PITS 11 Depth 4 Size Number <br /> SUMPS O. _Distance to nearest: Well Foundation Property Line .�. <br /> DISPOSAL PONDS ; <br /> 00177 11hereby 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•tRf;;San Joaquin,Local Health District. i <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 ,in thelperformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." ra <br /> .,rThe applicant mufit call for all requlrpclonspa5tions. Complete drawing on reverse side. r <br /> Signed Title: Date: <br /> ....�► <br /> ti s'FOR DEPARTMENT USE ONLY <br /> Application Accepted y Date 4 Area f' <br /> .. . <br /> Pit or Grout Inspecti by ;Date t� r Final Inspection by Date <br /> Additional Comments: <br /> 1C�^h Illy@ c�Dm D n7 Dl9j 6? 2. <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 11 Manteca 823-7104 ❑ Tracy 83546385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 1 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> r <br /> +,EH13-24MEV.1/s5) <br /> EH 14-28 <br />