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r <br /> \A C I <br /> ' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ! ` <br /> (f 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 4'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 7 •- �r[/ �li��� City { ,Lot Size PM <br /> Y36Owner's Name IACA�r Address O w' ' d� ~ Phone — 3 <br /> Contractor <br /> J� Address �22 /**icense No. 6 /3 Phone 1 <br /> TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR (7 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.�,f,., fPROP. LINE <br /> 4✓ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL c� / PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS �. <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> X Domestic/Private X Gravel Pack 10 Tracy Type of Casing� V(f, Specifications <br /> FI Public ❑ Other 71 Delta Depth of Grout Seal ` Type of rout <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 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 N <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION f 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 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll 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 DjMrict. <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 st call for all requir9l inspections. Complete drawing on r erse sidfi- <br /> Signed X Title: Date: 4-2(,1469 <br /> FOR DET USE ONLY 7 <br /> Application Accepted by J Date 9T�_ Area �J <br /> Pit or rot Inspection by Date �J Z Final Inspection by Q' JD�e <br /> Additional Comments: <br /> ❑ Stk 466-6781 . ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 IT, <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952pl.FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PE <br /> +.EH13-24 1REV.i i N a) <br /> EH 14.28 <br /> r <br /> r <br />