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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. t}�_ ,,y-_� /} <br />{ Job Address ��(�O� t7171D,�,GQ, - City '+�+'�'�' Lot Size ? E/ 9 PM <br /> 90 <br /> Address Pa• Zf - Phone <br /> Owner's Name c� <br /> Contract r Address�o. License No Z ZfO Phone 3 Icea `6LL. <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <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 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> k ❑ Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. f Well Casing <br /> C7 Domestic/Private LJ Gravel Pack ❑ Tracy Type of Casing Specifications r ` <br /> M Public (-I Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth t I Eastern Surface Seal Installed by <br /> k Repair Work Done ❑ Type of Pump H.P. State Work Done V <br /> tt Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> I . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION- REPAIR/ADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> ` available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Othe <br /> I Number of living units: Number of AeVrooms. �O <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mf Capacity-� No. Compartments <br /> PKG. TREATMENT PL ❑ �� t ( Method of Disposal <br /> Distance to nearest: Well_*ZSC�_ Foundation Property Line <br /> p i <br /> LEACHING LINE No. & Lengtttof lines r Total length/size ' <br /> FILTER BED ❑ Distance to nearest: Well..-_�QQ_ FoundationProperty Line <br /> SEEPAGE PITS Depth ~' .Size Number <br /> l _ r <br /> � .�..._ <br /> SUMPS """"""`' � L� Distance`to-nearest: Well•._ foundation f©_ Property Line <br /> DISPOSAL PONDS{� ❑ ' <br /> kt ' : , ` <br /> y f 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-io,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 squiredinspections. Complete drawing on reverse,si <br /> i <br /> Signed X - - �P_;I - - - Date: <br /> - - -j <br /> 0 FOR DEPARTMENT USE ONLY / <br /> Application Accepted by� Date,.5 Area' L — <br /> 1 or Grout Inspection byateJ s ` Final Inspection by atec <br /> Additional Comments: <br /> l ❑ 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 AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT*NO. <br /> INFO t t CASH <br /> 1 <br /> EH t3-24{REV. <br /> +.EH <br /> o-28 ll 11 <br />