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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ss:�rti (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 /> Job Address4 Ci (/`'� "~,i� �Lot Size PM <br /> r~"• ��� �. <br /> _ _ <br /> 777 <br /> / — <br /> Owner's Name _ . Address ° - 1 Phone <br /> I <br /> Contractor's Nam 4—Z- License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ J <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS •r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial C1Open Bottom []..Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy 'Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout f <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. N State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material (Below 501 f <br /> TYPE OF SEPTIC WORK: NEIN INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) � <br /> Installation will serve: Residence Commercial_ Other <br /> a ) <br /> Number of living units:�_ Number of bedrooms o2 <br /> Character of soil til a depth of 3 feet: Water table depth Cr <br /> SEPTIC TANK [K Type/Mfg Capacity_��4r No. Compartments <br /> PKG. TREATMENT PLT. ❑ ,. Method of Disposal <br /> a •. � � <br /> Distance to nearest: Well 54 Foundatior�n JAPAZ— Property Line <br /> LEACHING LINE Er'No. & Len th of lines " �Q <br /> g /1 Total length/size <br /> FILTER BED ❑, Distance to nearest: Well— -✓T Foundation_-Ll,4e'f- Property Line <br /> SEEPAGE PITS V11 Depthize 93 Number 17— <br /> SUMPS <br /> 7SUMPS ❑i Distance to nearest: Well 112LI4 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. <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 must call for alll required inspections. Complete drawing on reverse side. w r <br /> Signed XTitle: Date: <br /> FOR DEPAR MERIT USE ONLY <br /> Application Accepted by M Date 7"3 L Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-Ml ❑ 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 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO.' f <br /> +EH 13.26(REV.io1as) L.J/, o� `7 <br /> �� <br /> EH 13-26 I Y g 4 <br /> l 'a�-9 S .. <br /> 1 � <br />