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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR 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. p <br /> Job Address ` ' �UQ�R/V1 %-eeliV kA City f Lot Size PM <br /> Owner's Name A e-J2e 1A1QQ Address 3� b0gi t Phone <br /> Contractor 4 15'&ZZcr _ Address l!r`O MTS License No.r9, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT'O' DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TCr NEAREST: SEPTIC TANK SEWER L1NfS DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> f <br /> INTENDED USE �,- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIHCATIONS <br /> {❑ Industrial ❑ Open Bottom ❑ Manteca Excavation Dia. of Well Casing <br /> © Domestic/Private ❑ Gravel Pack ❑ Tracy -'^ type of Casing Specifications <br /> I'] Public Ll Other 17 Delta Depth of Grout Seal Type of Grout <br /> s <br /> I I Irrigation —.Approx. Depth I I Eastern S644ace Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P."- �" State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION F;EPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) �l <br /> Installation will serve: Residence Commercial r�Other <br /> Number of living units: --- Number of bedrooms__.--_._-_ <br /> Character of soil to a depth of 3 feet: A Rn 1?15 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg P&k, _ CapacitK141-No. Compartments <br /> -PKG. TREATMENT RLT,L},eq !�j Method of Disposal <br /> Distance to nearest: Well 67 <br /> V Foundation On`! Property Line <br /> LEACHING LINE No. & Length of lines — Total length/size <br /> FILTER BED ❑ Distance to nearest: Well-&;e­/:�r-Foundation %525'�7 Property Line <br /> SEEPAGE PITS I 1 Depth /6Size x �1�� !U Number <br /> SUMPS Distance to nearest: Wel[ 10026�� f=oundation ZQ Qom' Property Line c_ 7- <br /> DISPOSAL <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, a <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 Paws 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 perrriit 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. <br /> Signed X _ _ Tit[e: Date: <br /> � �- <br /> FOR DEPARTMENT USE: ONLY <br /> r Application Accepted by /iv Date Area <br /> Pit or Grout Inspection byDate Final Inspection by A 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 /> INFOFEE AMOUNT DUE AMOUNT REMIXED CK 4 <br /> CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13-24(REV.1/85) <br /> EH 1426 <br />