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APPLICATION FOR PERMIT <br /> k SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1`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 /> I Local Health District. n71 <br /> CJob Address City Lot Size PM <br /> Owner's Namex W �T K�IJ 1 __- Address AfAt Phone <br /> Contractor � <br /> C� Address <br /> L. License No. Phone <br /> - <br /> jTYPE OF WELL/F1UMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> y <br /> wy;j ^•PUMP INSTALLATI i SYSTEM REPAIR 1-11 OTHER LJ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERLINESDISPOSAL'FLD. PROP. LINE j •_"; <br /> FOUNDATION �-AGRICULTURE WELL OTHER WELL,�--.�_ PITS/SUMPS j <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC TIO aif [/ <br /> ❑ Indu ' 1 ❑ Open ottom ❑ Manteca Dia. of Well ExcAvation Dia. of Well Casing <br /> s omestic/Private ravel Pack ❑ Tracy Type of Casing Specifications / <br /> f'l Public n Other Cl Delta Depth of Grout Seal Type of Grout . <br /> I I Irrigation Y' 1 A -Approx. 1.1k1asem rface Seal Installed by 'Ci �Repair Work Done Typ -of PumpH.P. # s-' `� State Work Done <br /> Well Destruction ,© J Well Diameter w.`�`��"$ealing Material trop 50') ! r <br /> "D4th =1 Filler Material (Below 50') ' <br /> -TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR(ADDITION-I-1---DES-T-RUC-TiON-I4-(No.-septic system permitted if public sewer is h^ <br /> a available within 200 feet.I <br /> Installation will server Residence_ !Commercial' i' Other€ i <br /> vrr <br /> Number of living units: Number of bedrooms <br /> tit <br /> Character of soil to a depth of 3 feet: s Water table depth <br /> -,-SEPTIC TANK ❑ Type/Mfg } y Capacity No. Compartments <br /> I PKG. TREATMENT PLT. ❑ Method of Disposal <br /> jj Distance to clearest: Well ! Foundation Property Line 01 <br /> LEACHING LINE ❑ No:-& Length of lines Total length/size ? <br /> F <br /> FILTER BED ❑ Distance to nearest: i. : Well ( Foundation Property Line <br /> SEEPAGE PITS i I Depth Size . Number w , <br /> SUMP SCly Distance to nearesw, "Well Foundation Property Line <br /> DISP.OSALtPONDS ,❑ _' ,\j &- Y's <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`fcensed agent's signature certifies,the following:;J'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 fallowing: '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 I,iws of Cali rnia." <br /> The' pplica -most`cal for`a11'req fired" f0t.t I dtawing-o r sr - -- - J� <br /> Signed X ��Title: 'I- ` r / At <br /> --� Date: <br /> 2 4l <br /> F.OR-DEPARTMENT_USE:ONLY..— <br /> f Application Accepted by Date (4' '�' /I�t��1 Area <br /> Pit or Grout Inspection by Date a Final Inspection by l r' '1� Date <br /> r � <br /> Ad ilional Comments: <br /> `�Stk 466 6781 Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835-6385 <br /> r p licant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> k <br /> a <br /> lFEEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ry; <br /> EH 13.24(REV,t/y 51 r p 7 <br /> EH 14-26 1 O� - � / ��iK 197 <br />