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APPLiCATION-FOk PERMIT " <br />{' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON-AVE., STOCKTON, CA <br /> r Telephone (209) 466-6781 R <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r y <br /> * (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct arid/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1852 for well/pump and the Rules and Regulations of the San Joaquin . <br /> Local Health District.. <br />. Job Addre �J'll.� , .. � <br /> _ p City I Loft Size PM <br /> Owner's Na' /F"f)��' Address }tt0� •s' C%U( �'f'v - r- 'ql — 33 I <br /> Phone <br /> Contractor t Address 's 1 <br /> License No.' Phone <br /> TYPE OF WELL/P0 ` NEW WELL ❑ ,E WELL,RFPLACEMENT ❑ - DESTRUCTION ❑ <br /> I <br /> UMP INSTAL TION ❑ SYSTEMEPAIR ❑ OTHER ❑ ; <br /> DISTANCE TO NEAREST: S TIC TANK SEWER LiNES _ — DISPOSAL FLD. PROP. LINE <br /> 1 FOU ATION Al RICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDEp�USE TYPE OF WELL PR BL AREA CONSTRUCTION SPECIFICATIONS <br /> r <br /> ❑ Industrial " ❑ Open Bottom Manteca Dia. of Well ExcaSati`on Dia, of Well Casing <br /> ❑ Domestic/Private ❑ Gravel_ Pack ❑ Trac g ` r ' I Spec <br /> Type.of Casinifications <br /> ❑ Public A% ❑ Other ❑ Delta _ D th of Grout Seal <br /> ❑ irrigation f 1 Type of Grout <br /> ppr . Depth ❑ Eastern Surface Seal installed by *` ' <br /> Repair Work Done ❑ Type'of Pump H P <br /> State Work Done`• <br /> Well Destruction, ❑ Well Diameter ,'Sealing Material (top 50') i <br /> ,. _ '-K <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ 'REPAIR/ADDITION ❑ DESTRUCTION: {No septic system permitted if public sewer is <br /> ifavailable within 200 feet.) ' <br /> Installation will serve: :Residence_ Commerciai_ Other _ <, <br /> Number of living units: "" Number of bedrooms <br /> Character of soil to a depth of <br /> .3 feet: <br /> F Water table depth <br /> SEPTIC TANK ❑ T}ipe/Mfg "''"""•"" Capacity No. Compartments f <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> �. <br /> / Distance,;o earest: W f'�Y Foundations Property Line <br /> LEACHING LINE ❑ No. & Length o nes [ <br /> Total length/size <br /> FILTER 8ED ❑ Distance to nears t: ^Well i Foundation tProperty Line f - <br /> SEEPAGE PITS ❑ Depth Size } Number <br /> SUMPS ; ❑ Distance to nearest: Welly Foundation�� property Line <br /> DISPOSAL PONDS [] ,. <br /> I hereby certify that I have prepared this applicaiion 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 no <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 must A for all requlred inspections. Complete drawing on reverse side. <br /> Signed 1 r --«. �" +1 ...,r Title: <br /> - ,Date: - <br /> FOR•DEPARTMENT USE ONLY <br /> Application Accepted byDate Area <br /> u <br /> Pit or Grout Inspection by Date Final in by <br /> Data <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 852(}1 <br /> A <br /> { <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIVED BY DATE PERMIT N0. <br /> + EH 13-24 EH 14-28 iREV.7/a51 - <br /> u <br />