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APPLICATION FOR PERMIT <br /> a , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1801 E. HAZEL—WN AVE.,:STOCKTON, CA <br /> Telephone (209) 466-8781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ <br /> (Complete_jn Triplieatel-i <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 /> H. Bir S City ' f Lot Size PM <br /> Job Address <br /> Owner's Name <br /> rl ' Address �� �/ 'V r l �n 7&J.- <br /> `� - Phone �- <br /> Ob Address J'a_ 76� v' ""`r License No. V�262 Phone <br /> Contract 0 <br /> TYPE OF WELL/PUMP: I�' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1:1 <br /> 1 t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.' PROP, LINE 111 <br /> r s # FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r I <br /> ❑ Industrial ❑ OpenBottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑1Gravel Pack ❑ Tracy Type of Casing Specifications ' <br /> ❑ Public ❑'Other ❑ Delta Depth of Grout Seal — Type of_Grout <br /> " ❑ Irrigation �pprox. Depth ❑ Eastern SurfaceSeal-Installed-by - <br /> Repair Work Done LJ Type of Pump H.P. State Work Dane / <br /> Well Destruction C1 Will Diameter Sealing Material (top 50') f <br /> 1-"-'Y _DepX <br /> th ' ' er Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIR/ DDITION <br /> DESTRUCTION-❑ (No septic system permitted if public sewer is <br /> �q {iiVailable.within 200 feet.) <br /> r4 4 <br /> Installation will serve: Residence, Commercial_i Other t� j <br /> Number of living units: �`-Number-of- rooms i L / <br /> Character of soil to a depth of 3 feet: - �!-�t � ���III : Water table depth J <br /> SEPTIC TANK ❑ Type Mfg ! Capacity— <br /> apacityNo. Compartments <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> e <br /> :Distance to nearest: Well Foundation Property Line <br /> LEACHING-LINE- a No. 81 Length of lines �f Total length/size <br /> FILTER BEQ l ❑ i Distance to nearest Well_-,5:40 Foundation Property Line -_— <br /> i SEEPAGF,ITS i Depth J —Siz r <br /> ~y �.' fF Number <br /> SUMPS r l _❑ I Distance to nearest: Well-1106QQ �Foundation�Q_._— Property Line le e .— <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. i. f <br /> Home owner or licensed agent's signature certifies the following: "I certify tKat in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manna to-become,su6ject to-w orkman's-compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify Fiat`in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws oCalifornia.'* <br /> The applicant mu t call for allqui* d inspections. Complete drawing on reverse side. <br /> _Title: Date: <br /> Signed _ <br /> FOR PARTMENT USE ONLY <br /> Application Accepted by <br /> ,1i. Date V Area <br /> 1, <br /> kit r Grout Inspection by --Ltate����Final Inspection by j�� Date, 1 . <br /> Additional Comments: ` <br /> ❑ Stk 466-6781 i 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 /> R EI <br /> ! IFEENFO <br /> AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT•NO. <br /> + EH 73-24 IAEV.i/e 5t <br /> EH 14-26 <br />