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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 /> r <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 City C V Lot Size PM <br /> !+`1 UDS TQ <br /> Owner's Name �'�r Address Phone <br /> r <br /> Contractor i L i i A d essA4RA License No..22S522—Phone r i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ =OTHER ❑ <br /> DISTANCE TO NEARESTrSEPTIC-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 O. <br /> ❑ Industrial ❑ Open Bottom # F ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0< i <br /> ❑ Domestic/Private _.❑.Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public 0 Other ❑ Delta Depth of Grout•Seal Type of Grout <br /> I ]_,Irrigation _.._ _Approx. Depth i I Eastern Surface Seal Installed by _ "v <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Weil Diameter Sealing Material Stop 501 <br /> F —,Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION>e DESTRUCTION l I (No septic system permitted if public sewer is f <br /> + available within 200 feet.) Jf <br /> Installation will serve. Residence 1 _Commercial_ Other <br /> 3 <br /> Number of living units:. .Number of bedroom's�— <br /> Character of soil to a depth of 3 feet: ,A 1)0 C CE Water table depth <br /> SEPTIC TANK * ❑.'"'.Type/Mfg,—,;�i x Capacity No. Compartments I <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest:a Well Foundation Property Line <br /> LEACHING LINE ❑ ^ No& Length of)inbs 7 c3r Total length/size <br /> FILTER BED ' Distance to nearest: Well-Z4—" Foundation 4G —_' Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS -.-.0. <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 /> Horne 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 must call for all re uire inspections. Complete drawing on reverse side. <br /> It a <br /> Signed X .K- _ Title: v Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> r � <br /> Pit'or Grout Inspection,,by,„.-- Date Final Inspection by Date/.14 w <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 Cl 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 <br /> INFO AMOUNT,I]UE ..AMOUNT REMITTED .CASH" '''RECEIVED BY TCK 4 "r­-DATE- PERMIT'NO. <br /> r EH 1324 T REV. /H 51 V / s ��'� <br /> EHA4-26 111 VVVV CCC...JJi S.7 , <br />