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I <br /> �J r APPLICATION FOR PERMIT <br /> f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �D <br /> 1 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is he+eby,made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> II 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 Address �_�c�� ' City �' � Lot Size PM <br /> 1 <br /> Owner's Name tL2e5Address ` Phone L� <br /> Contractor. "�-� �°�'� = Address S� - �� License-No. �� 'Z� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT d DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ O <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 <br /> ❑ Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> t a_Domestic/Private El Gravel Pack El Tracy Type of Casing Specifications <br /> M Public 171 Other Cl Delta Depth`lof Grout Seal Type of Grout <br /> I Irrigation --Approx. Depth I I Eastern ;n Surface Seal Installed by <br /> Rbpair Work^Done ❑ Type of Pump H.P. rState Work Dane— <br /> k' Well Destruction` ❑ Well Diameter Sealing Material (top 501 r <br /> Depth Filler Material (Below 50') t <br /> TYPE OF SEPTIC WORK:- -NEW INSTALLATION REPAIR/ADDITION t I DESTRUCTION 1 I (No 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 .1 ­1 + t (� <br /> Character of soil to a depth of 3 feet: Z.a �� Water table depth <br /> SEPTIC.TANK L�Type/Mfg -47,1a (fyN� Capacity�scad CD No. Compartments Z <br /> PKG. TREATMENT PLT. ❑' Method ofDisljosal <br /> Distance to nearest: Well 9r1 ' Foundation Property Line <br /> LEACHING LINE 9" No. & Length of lines 7 S. Total length/size r <br /> FILTER BED U--Distance to nearest: Well Foundation 3 Property Line e 2 �p <br /> SEEPAGE PITS t I Depth Size'sZ " Number <br /> SUMPS ❑# Distance to nearest: Well / Foundation ��� y Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t 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. e <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 subcontracting 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." w ! <br /> fi The applicant must call r all squired inspections.'Complete drawing o reverse side. <br /> Signed X Title: ��� Date: <br /> FOR DEPARTMENT-USE-ONLY _ <br /> op <br /> cation Accepted byvk4Date �� Area _C)l <br /> i r �� p 7��QC dr//17�C.�'Date <br /> Grout Inspection by "'U` T Date Final Inspection b1 T____. <br /> w <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. Bax 2009, Stk., CA 95201 - <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO y/� <br /> + EH 13-241REV,t/N 51 q • ®� <br /> EH 14-26 / - <br />