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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) yAp�-Z�� x <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein,�e� ' cation is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and o the San Joaquin t <br /> Local Health District. <br /> Job Address-33? City Lot Size PM <br /> Owner's Name C441 Address A_44,44,%� Phone <br /> Contracto Address�a - _ z"—�L'icense NadA5P3947— Phanlv3s <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> PUMP INSTALLATION ❑� SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION- AGRICULTURE WELL ..OTHER WELL -_ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (`l Public 1 0 Other tl Delta Depth of Grout Seal Type of Grout <br /> I ) Irrigation —Approx. _Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ' Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material-(top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth g <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments fr1 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines _ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS ❑ - Distance to nearest: Well. Foundation Property Line <br /> DISPOSAL PONDS ❑ . , <br /> I hereby certify that Phave prepaied this-application and that the work will be done in accordance with-San.-Joaquin county ordinances, state laws; and')i_ � <br /> rules and regulations of the San Joaquin Local Health Diltrict. <br /> Home owner or licensed agent's signature certifies the following: 1 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: 1 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 applica I for all repired inspections. Complete drawing on averse side. i <br /> Signe X Titley ---- _ Date: 1 <br /> x FOR DEPARTMENT USE ONLY r <br /> - -p 4 <br /> Application Accepted by Date �7 4�� Area <br /> Pit or Grout Inspection by ate Final Inspection by Wil/I Date aa�w <br /> Additional Comments: <br /> 0 Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 0 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 CK 4 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> '7 O <br /> +.EH 13-24(REV.final J)5 �S J��r .7 �Z <br /> EH 14•28 4/ <br />