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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 /> 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 Lot Size PM <br /> Owner's Name Address <br /> V 19SkEc'rDJ t{ 7'1N6 r,F+.z cv�ro�noa..�� S'32- ?(o02- m <br /> Contractor Address O Q`S��lLicense No. ��� Phone_ G <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑- OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> _FQUNDAT.ION-�--- - -� -AG RICULTURE-WELC�"r`—'OTHER WELL PITS/SUMPS <br /> Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> *pomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ['1 Public ❑ Other L-] Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation T-Approx. Depth I I EasternSurface Seal Installed by <br /> � _ <br /> Repair Work Done ❑ Type of Pump, .&A! H.P. 4f�j State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 <br /> - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I ] DESTRUCTION I 1 (No septic system permitted if•puhlic,seiv„ <br /> eqis, <br /> available within 200 feet.l r— } �' , <br /> Installation will serve: Residence_ Commercia1 Other' J Q . <br /> Number of living units: Number of bedrooms Y .. <br /> Character of soil to aedepth of 3 feet: n Water liable depili <br /> K El <br /> SEPTIC TANType/Mfg t Capacity= No. Compartments <br /> PKG. TREATMENT PLT. ❑ t Method of Disposals - •-• ,-, -++ �- <br /> J.r�+ 1 <br /> Distance to nearest: Well 1 Foundation ' Property Line rtGt \!tr'pr <br /> 1 <br /> LEACHING.LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED~r ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size _ Number <br /> SUMPS ❑ Distance:to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ F <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 perforrnance of the work fdr whicfithWpermit 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 t c r all required inspections. Complete drawing on reverse side, ` —1 <br /> Signed Title: JQ,4 -- Date: <br /> /eIA� FOR DEPARTMENT USE ONLY � <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> i <br /> Additional Comments: <br /> ❑ 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH=-r RECEIVED BY DATE PERMIT NO. <br /> �.EH 13-24(REV.I/K 5) 35 GA F ����� ��/�' ✓/ <br /> EH 14-28 r J <br />