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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) l <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. n" <br /> Job Addresss�55 , " (_� (1J City nC,910A) Lot Size a­T <br /> PM <br /> Owner's Name s Address B0 Phone ' <br /> r <br /> Contractor ss /� <br /> License Noo-60 -Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK • 0�6 SEWER LINES F DISPOSAL FLDA_)6ZJ-_ PROP. LINE <br /> FOUNDATION 3p AGRICULTURE WELL,IrZ� OTHER WELL1,b4 6 PITS/SUMPS/C.C)A)C <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Welt 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 /> ElIrrigation _Approx. Depth� Easternpp❑',,,,��, Surface Seal Installed by � <br /> Repair Work Done f Type of Pump -WOOMH.P. 1 <br /> - State Work Dane � } <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ ether <br /> Number of living units: Number of bedrooms 4 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC"TANK ❑ Type/Mfg Capacity No. Compartments w f <br /> PKG. TREATMENT PLT. ❑ Method of Disposal # <br /> Distance to nearest: Well Foundation Property Line a <br /> " f <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line y <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> t <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 not <br /> employ any person in such manner as to became 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 Califnr I �_ I <br /> The applicant rfiu call for•all required in�omplete' ing"onreverse side. ISigned itle:�j�l Y ► C Date: <br /> �� F <br /> �. F DEPARTiNENT USE ONLY J r <br /> Application Accepted by v v Date /!—�f a [J� Area Q I. <br /> Pito Grout I pection by ,�� o.. r,_nate ^� "� Final Ins �--� <br /> pectin by JCLL&I y�Q "Date <br /> 4" t <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> µ INFO AMOUNT DUE AMOUNT REMITTED -CA H RECEIVED BY DATE PERMIT`NO, y <br /> + EH 13.2$[REV. <br /> EH 1426 i/est �" —013 <br /> — -- /015-0 a iG <br />