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y APPLICATION FOR PERMIT <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT .4. <br /> 1601 E. HAZELION AVE., STOCKTON, CA <br /> Telephone 1209) 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. <br /> . SCity <br /> Job Address / Lot Size PM <br /> Owner's Name LQ • .a-�l . Address 27 7,V3 hone <br /> Contractor Address .�5 License No._oZ.� �3 Phone <br /> TYPE OF WELL/PUMP: V NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _J� SEWER LINES DISPOSAL FLD../eD 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 /> Vf Domestic/Private k Gravel Pack )d Tracy Type of Casing Specifications `'' <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _ ��90 f Type of Grou <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface 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 ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Install on will serve: Residence Commercial— Other { <br /> Number of'tnripg units: Number of bedrooms \ <br /> Character of soil to a Beptft-qf 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Elr Method of Disposal <br /> Distance to nearest: Well=- wFoundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines TotafuNthlsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Pro a In <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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. Z <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."Contractors 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 appli ust call for all reginspecti ns. Comp dra 'ng on reverse side. <br /> Signed ` <br /> Date: � <br /> FORD TMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by M Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ L6di 369 1 ❑ Manteca 7104 ❑ Tracy 835.6385 <br /> Applicant- Return ail copies to: Environmental Health Permit/Servioes 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED PERMIT NO. <br /> INFO RECEIVED BY //{DALE <br /> + (REV.1laEH U-28 <br /> -^I� ` �� �� � a• ` r-f 'ZF� �� <br />