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APPLICATION FOR PERMIT ( <br /> I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 .'s�f f, Ei <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,, F <br /> I G s`.NTRL HEALTH <br /> dk �y <br /> (Complete in Triplicate) FERMIf/SlERVICES <br /> Application is heteby 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 Address417/ JCJL(.c,::K-t IV City ��' "" Lot Size PM <br /> Owner's Nam '` t Address`4�7r/ G��t �6 � Phone <br /> Name <br /> Contractor f' Address `,f _ def_' License Nt� .? Phone/ -f4 ), <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR e-' OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I <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 "Dia."of Well Casing <br /> ❑ Domestic/Private: ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (l Public Ll Other Cl Delta Depth of Grout Seal Type of Grout <br /> I <br /> nyatian T-Approx. De I I Eastern 115ce Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. J State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50'1 " <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I I DESTRUCTION ( I (No septic system permitted it 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 i6 a depth of 3 feet:` Y _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <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 ❑ DistanceTto nearest Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size i Number <br /> SUMPS Ll Distance to nearest: Well t Foundation Property Line <br /> DISPOSAL PONDS ❑ ) <br /> 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: ;l certify that in the performance of the work for which this permit is issued, I shall not I <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 i <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 /> t <br /> The applicant t call or all requir inspections. Complete drawing on reverse side. <br /> Signed X_ �it(e: / •,,.,,,_-- Date: <br /> •--'� 1 <br /> R DEPARTMENT USE ONLY <br /> i <br /> Application Accepted by Date" Area <br /> Pit or Grout Inspection by Date I Final Inspection by Date <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 /> i <br /> INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT-6170 <br /> ♦ EH13.26(RE <br /> EH 114-26 V,1/8 5) ` <br />