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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 /> r 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 /> Qr0 <br /> Job Address calom PS - J• e— City Lot Size k PM <br /> Owner's Name .fi-'•Fz C42f, •!/Address s QS filgone <br /> Contractor Address___ L7® License No. t 0 ya Phone a <br /> TYPE OF WELL/PUMP: NEW WELL ❑, WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION.❑ SYSTEM REPAIR ❑ - OTHER ❑ i <br /> DISTANCE TO NEAREST:YSEPTIC_T.ANK_ .SEWER LINES ......._._._...._.._..._ DISPOSAI«`fl-6 -�... .-PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PIA/SUMPS <br /> INTENDED USE„:” ,-X;TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial '°' ❑,Open Bottom'�',2- ❑ Manteca, Dia_.,ofrWell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public a ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by r <br /> Repair Work Done ❑i, Type of Pump H.P. State Work Done <br /> s <br /> Well b estruction'. ❑� Well Diameter Sealing Material (top 501 I <br /> Depth ` '�' Filler Material (Below 501 <br /> TYPE OF`SEPTIC,,WORK,:# NEW INSTALLATION, REPAIR/ADDITION DESTRUCTION LJ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation wil�'rve:�Residence- Commercial— Other <br /> Number of living units: Number-o.•bedrooms <br /> Character of soil to a depth of,-3,feet: - Water taKie depth <br /> SEPTIC TANK ❑ T ~ " <br /> ype'/Mfg_- Capacity No. CoMr partmagts i <br /> ,PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line R <br /> LEACHING LINE ❑ No. & Length of lines. Y Total length/size I I <br /> FIL- ER BED ❑ Distance to nearest: Well t Foundation I Property Line <br /> SEEPAGE PITS Depth s r Size 1 )Numb r <br /> SUMPn <br /> S ❑ Distance to nearest: Well Foundatio ; � Property Line 90 4 <br /> DISPOSAL PONDS ❑ ; <br /> I hereby certify that I have prepared this application and 06t the work ill be done'in.accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San.Joaquin-Local-Health-District:-- ----­ i ' -) I <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 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 app)' n mu II for all re ired inspec ions. mplete drawing on reverse side. <br /> �� �� <br /> .. <br /> Signed - f. � � Title: _ Date: <br /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date G r <br /> Additional Comments: IIVI <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. Hazehon Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. <br /> CASTI <br /> + EH 1324(REV11/85) 1 �� ()V ""t 0 o i �C- t tut <br /> EH 14-28 `V `� �J'� <br />