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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 /> x: (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 4� rl0 JE,; City Lot Size PM nn <br /> Owner's Name 1Address � Q �JppfrA.v� �S Phone <br /> f-;Contrjct Address ��C•_'l�D7C �JC.(t c� License No.t 2 2 Z(1 Phone 361510S` <br /> TYPE OF WELL/PUMP:.., ; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 1''. . -!' 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 rL ` <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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> —Repot+Work=t'1ciie�--C --Type•of-Pump --�---�---�---_ }i:P— - — -T--State Work-Done--- .----x.----_. ..Well Destruction ❑ Well Diameter ,Sealing Material (top 50T "rt <br /> _Depth. Filler_Material.(Below-50 ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION OREPAI ADDITION K DESTRUCTION ❑ !No septic system permitted if public sewer is <br /> f T available within 200 feet.) <br /> Installation will serve: Residence vCommercial er OthN _ w <br /> Number of living units: Number of bedrooms _ _ <br /> Character of soil to a depth of 3 feet: -€�` Y .r T Waier table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r <br /> PKG. TREATMENT PLT. ❑ 7 s <br /> < �� Method of Disposal . <br /> Distance to nearest: Well { `Foundation ,P_roperty Line <br /> LEACHING LINE 174--'-No. & Length of lines �"� Total length/size <br /> FILTER BED ❑ Distance to nearest: Well IC(? Foundation--10-' -Property Line__s <br /> SEEPAGE PITS Depth Size � Number I <br /> SUMPS ❑ Distance toav ,We <br /> DISPOSAL PONDS 11 eot ` Foundation ` Property Line _ <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 /> 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'noi. <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting si natui­ s <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'cort5pertsa .' y` <br /> tion laws of California." t <br /> The applicant m t call for all r quir inspections. Complete drawing on reverrsef si Jo <br /> Signed Title: V •1 ' Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Data _ Final Inspection by �I4 Date A. <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835463$5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> E: <br /> CK 0 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO, tai <br /> + EH W26 24IREV.t/e5) <br /> EH 14- �7d , 1/( S 6- 7-2:7 <br />