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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR,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 /> I 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. x <br /> fw _ <br /> I Job Address 0 f D r'G City 1�yCgtr W10I Lot Size 1141 CLCD 5_ PM <br /> "' Q <br /> Owner's Name T� Address t�W p, � Phone <br /> Contractor L, Gfi 0,55 6;n-a5 ' '� Address. f' License No.%S&Wi!V Phone 7Ycf"^ -2? <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ - <br /> PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER D <br /> i DISTANCE TO NEAREST: SEPTIC TANK h f SEWER LINES DISPOSAL FLD. PROP. LINE Ile <br /> # FOUNDATION AGRICULTURE WELL — OTHER WELL—AK!--PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f� <br /> El <br /> . <br /> � ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation � _ Dia. of Well Casing <br /> Domestic/Private D Gravel'Pack ❑ Tracy Type of Casing re-rL" Specifications <br /> [TPublic D OthGer�f, D Delta Depth-of-Grout Seal SO� Type of,Grout~'iSAe a. <br /> I I Irrigation _Approx. Depth I FEastern Surface-Seal Insialled-by IIG1R1Li 1p� _ <br /> a,.,.-Repair Work Done CJ Type of Pump '" ""`H:P: '" '� State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> I Depth Filer Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRYADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation Residence_ Commercial— Other 4ti <br /> Number of living units: umber of bedroom_s t't! <br /> 6aracter of soil to a depth of 3 feet: W e depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well tion Property.Line <br /> t LEACHING LINE D No. & Length es To ngth/size <br /> r <br /> FILTER BED ❑ Dist o nearest: Well Foundation Prop ine <br /> r <br /> ? SEEPAGE Pt I 1� Depth -Size Number <br /> Y <br /> I SUM 0 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 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 shat!not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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 /> I The applicant must call for all required inspections. Complete drawing on reverse a�side. <br /> fii <br /> Signed X �o�ILrtaJ4 Title: LG[WJ,4 Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date p Area r <br /> Pit orGrout nspection by DateA� _sFiinaal inspection by e f Date <br /> Additional Comments: <br /> 1> ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 0,%Z4 <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 _ANM6UNT REMITTED C SH RECEIVED BY DATE PERMiT'NO. <br /> INFO <br /> *.EH 13-24(REV,i/n s) <br /> EH 14-26 <br />