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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> z - 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> r PERMIT EXPIRES TYEAR 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 /> 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 /> f <br /> Job Address �� Y-0 . S — City G D 6 , Lot Size_ yd 614 � PM <br /> Owner's Name /fI Address es P t ems _ - <br /> ! cLe _ Phone J tv (/76 <br /> Contractor([�/t _� H Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL )4 WELL REPLACEMENT ❑ DESTRUCTION El <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ' r FOUNDATION AGRICULTURE WELL 420 "" OTHER WELL PITS/SUMPS <br /> INTENDE6 USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation m /,� Dia. of Well Casing <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public I Other Cl Delta Depth <br /> Grout Seal `�h Type of Grout C'j"414 1 <br /> I I I Irrigation ALL iApprox. Depth 4 I Eastern Surface Seal Installed by - <br /> e H,P. C2 State Work Done_4 <br /> Repair Work Dane ❑ Type of Pump a , <br /> I Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 N <br /> Depth .Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 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 /> j Number of living units: r Number of bedrooms ' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. <br /> El <br /> 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 /> r <br /> SEEPAGE PITS l 1 Depth Sizesl t Number i 0 <br /> i SUMPS F1 Distance to nearest: Well_ - —Foundation L._ — Property — <br /> DISPOSAL PONDS D <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, ands. <br /> rules'and regulations of the San Joaquin Local Health Diltrict. <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 California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. y <br /> f (� - <br /> s Signed X ,D. Title: Date: _/+ <br /> --� - O REPARTMENT USE ONLY <br /> Application Accepted by Data Z Area <br /> Pit or Grout Inspection by Date 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 /> FEE MOUNT DUE A RUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> +.EH13-24(REV.F1n5) <br /> EH 14-26 < <br />