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APPLICATION FOR PERMIT <br /> f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 T. <br /> A PERMIT EXPIRES 'I 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. r y <br /> Joh Address ;Z �/ — Ci Lot Size PM <br /> i <br /> � <br /> uress f ^ � -- PFone� <br /> Owner's N e I dPh57 <br /> one <br /> Cotractor Addres - - _License Na. <br /> TYPEWELL/PUMP: <br /> � l <br /> E <br /> OF WELL/PUMP T .'NEW WELL"❑; i WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES- -DISPOSAL FLO. - PROP,.LINE <br /> ` DISTANCE TO NEAREST:,SEPTIC,TANK. .. � <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 1. PITSISUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t : <br /> r❑'Domestic/Private ❑ Gravel Pack ❑.Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by 9 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done r <br /> f Wel! Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material {Below 501 I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION`. _DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> r available within 200 feet.) <br /> Installation will Lserve: Residence.". Commercial— Other � Ilk G h -�+0 <br /> I. 1 S r��" I G *"�4 K R .ri <br /> Number of living units: Number of bedrooms � •�+ <br /> Character,of soil to a depth of 3 feet: ` ' "^'-- Water tab a depth <br /> SEPTIC TANK ❑ TypelMfg <br /> Capacity No. Co <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r <br /> - Distance to nearest: Well Foundation Property Line <br /> F l <br /> LEACHING LINE ❑ No. & Length of lines ` "Total length/size <br /> FILTER BED ❑. Distance to nearest: Well Foundation Property Line <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, sate laws, and <br /> ` rules and regulations of the San Joaquin Local Health District. <br /> ` Home owner or licensed agent's signature certifies the following: "1 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 st call or lr inspe tions. Complete drawing on reverse side. <br /> drawing / <br /> Signed Title: �_�s�i�y f_ _ - .. Datef <br /> i - i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ` /JZLArea O <br /> Pit or Grout Inspection by Date Final Inspection by ✓ Date <br /> Additional Comments: <br /> ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7.104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO, <br /> INFO 77�� r� r / <br /> + EH 13.24(REV.118 5) 7&dV IRd -�O <br /> EH 14-28 <br />