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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEJON AVE., STOCKTON, CA <br /> { Telephone (209) 466-6781 <br /> PERMIT EXPIRES'1 YEAR FROM DATEISSUEDni <br /> ` <br /> (Complete in Triplicate) . <br /> c. ' �t4,. �� i;�._ •i�„ . . , <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 Address,)d la '4 � "' 4 City c { Lot Size PM <br /> a <br /> Owner's Name ,c­ZVL -t_> Address a d to ' Phone,34. 13 <br /> Contractor Address J O ,��yR„License No.Al 2 P h o n e 13L <br /> TYPE OF WELL/PUMP: NEW WELL ❑ r u,`- DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ -.SYSTEM REPAIR OTHER Ll t� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L ESQDISPOSAL FLD. PROP. LINE V <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial E ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.-of Well Casing n <br /> dd'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other D Delta Depth of Grout Seal Type of Grout <br /> r <br /> ❑ Irrigation ---Approx. Dep EJEastern Surface Seal Installed by s <br /> Repair Work Done �' Type of Pump H.P. 1 State Work Done <br /> R� 940 <br /> Well Destruction ElWeil Diameter Sealing Material (top 501 ` <br /> Depth Filler Material (Below 50') �+ ,� %.0 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTIONr❑ (No`septic system permitted if public sewer i <br /> available within 200 feet, q <br /> i ,,Installation will serve: Residence_ Commercial_ Other <br /> , � 1 <br /> F Number of living units: Number of-bedrooms <br /> i <br /> i Character of soil lo a depth of 31feet �f Water table depth <br /> SEPTIC TANK I ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENTPLT. ❑ Method of Disposal ~ <br /> Distance to nearest: Well Foundation Property Line <br /> i jl <br /> LEACHING LINE ❑ No. & Length of lines ! Total length/size L <br /> FILTER BED ❑ Distance to nearest: ''Well Foundation Property Line' <br /> SEEPAGE PITS ❑ Depth 5ize Number j <br /> ! ' <br /> SUMPS ❑ Distance to nearest: Well foundation ..Property Line it <br /> DISPOSAL PONDS, ❑ <br /> I hereby certify that,l 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 performancalof the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." r <br /> The applicant st`c II for all req ed inspections. Complete drawing o verse side. <br /> �/� i <br /> Signed X� -!/vile: Dat y <br /> y� f <br /> FOR DEPARTME T USE ONLY <br /> A (tet <br /> Application Accepted by fW12 ���+-U 1 Date *T Arree`a�/ 2-- <br /> Pit or Grout Inspection by Date-)-F Final Inspection by�- "— '"Date��� <br /> .I <br /> 4 <br /> .Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104,E .D Tracy 835-6385 <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 CASH <br /> + EEH 14-26 H 13-24(REV-1/85l <br />