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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ~ <br /> IComplete 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. 1852 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. l _ 4 <br /> Job Address ! 7 Lt� City toc Lot Size PM <br /> Owner's Name es—se— Orgz d_ Address .4JIlly j,-cay OSCE C&rezz Phone +3 <br /> T <br /> Contractor.l.L GRa.W4­140� Address_�7.2 34ASO-r— tt License No.��3c�r5� Phone 'I �? <br /> TYPE OF WELL/PUMP: NEW WELL 31/ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 9?" SYSTEM REPAIR ❑ OTHER ❑ <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 a e� <br /> ndustrial ll�^6pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 5reee Specifications <br /> FI Public n Other n Delta Depth of Grout Seal J Type of Grout ? <br /> I I Irrigation 34Y&-Approx. Depth I I Eastern Surfac_q Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump- - H.f, AD'q' State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 T <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartmentsry <br /> PKG. TREATMENT PLT. ❑ Method 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 /> SEEPAGE PITS I 1 Depth Size _ _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 Di§trict. <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: '9 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 re aired inspections. Complete drawing on reverse side. <br /> Signed X 4 Title: Date: E 1 CJ`1 tJ <br /> FOR DEPARTMENT USE ONLY ��rr��,((�� <br /> Application Accepted byQ Jb-K JV n[��.l .._ Date �1 'GIB Area ,� <br /> Pit or Grout Inspection by Date/J.l� Final Inspection by Date/ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT <br /> DUE AMOUNT REMITTEDCr-K_H/ RECEIVED BY DATE PERMIT'NO. <br /> ♦,EH 14-241REV.riH5) Ol ®`W -j� 7[-•y I�� �I(Y l 31 <br />