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APPLICATION FOR PERMIT <br /> 3 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-67811 , <br /> PERMIT EXPIRES 1 YEAR FROM .DATE ISSUED JUN 1 ? 1988 <br /> (Complete in Triplicate) <br /> EN I &EA <br /> T�, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her ' i is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules an oaquin <br /> Local Health District. <br /> �/ �� Lot Size PM <br /> f <br /> Job Address �� � -916 ,41- City r <br /> Owner's Name Address Phone <br /> Contractor's Name / ►' License No. 7� Phone <br /> AJ- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> f PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 Dia. of Well Casing <br /> DomesticIPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I <br /> Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> i ❑ Irrigation --Approx. Depth ❑ Eastern ) Surface Seal Installed by <br /> Repair Work Done El Type of Pump H.P. f State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 0 <br /> a'TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installationwill serve: Residence Coat cial_ Other <br /> Number of living units: Number of bedroo <br /> Character of soil to a depth of 3 feet: Water table depth s <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to ne st: Well undation Property Line <br /> LEACHING LINE ❑ No. & ngth of lines. Total length/size <br /> FILTER BED ❑ Dist ce to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth t Size Number <br /> SUMPS ❑ Distance to nearest: .Well = Foundation„ Property Line <br /> DISPOSAL PONDS ❑ <br /> a 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 become 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 mu call or all red' spectio Co to awing on revgxsg siftL <br /> _ <br /> Signed X J / Title: Date: <br /> R DEP RT NT USE ONLY <br /> Application Accepted by ( Date Area Q <br /> t <br /> Pit or Grout Inspection by Date Final Inspection by -277% Date <br /> Additional Comments: <br /> ❑ Stk 4664781 ❑ Lodi 369-3821 ❑ 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 /> FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO.. <br /> f INFO CASH I� f <br /> + EH 13-21(REV.10183) 3 YJ V� <br /> EH 1426 <br />