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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6181 <br /> PERMIT EXPIRES 1 YEAR FROM„DATE ISSUED <br /> (Complete in Triplibate) <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 F_2J WET)t. ��1 M2= City Lot,Size• Ply <br /> Owner's Name Address •141—/ �T/� 5. Phone” 'J <br /> Contractor_� ddress_�/�d (�J�/,�G /ricense No, Phone <br /> TYPE OF WELL/PUMP:----«... . _ .:_-NEW WELL-Q, ..-Y ---WELL-REPL•ACEMENT•❑,.»-.�.-�-DESTRUCTION ❑ <br /> PUMP INSTALLATION ? SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f FOUNDATION r- AGRICULTURE WELL-! OTHER WELL PITS/SUMPS �- <br /> -INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial . ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ bther ❑ Delta Depth of Grout Seal Type of Grout <br /> R)Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> I Repair Work pone ❑ Type of Pump H.P. _ <br /> ----.State Work Done / If�l�D <br /> { <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') 8.' <br /> Depth Filler Material Melow 50.1 + <br /> TYPE OF SEPTIC WORK.: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is S <br /> available within 200 feet.) <br /> Installation will serve:/Residence a Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth- <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ _ ,4 _ �-, a., . Method of Disposal <br /> > Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/siie <br /> FILTER BED ❑ ..Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS O Depth Size' r "" '" `° +Number <br /> f SUMPS ❑ Distance to nearest: Well- w Foundation Property Line <br /> F ' j DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and thatthe work will be done in accordance with San Joaquin`countyordinances, state laws, and <br /> `rules and regulations of the San Joaquin Local Health-District.. ; - J <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."Contractors 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." r �. <br /> The applicantmust Ifo II re r inspections. Complete drawing on raver de.j <br /> Signed�., Title: — Pate: Z21 <br /> " FOR DEPARTMENT USE ONLY <br /> 6 <br /> Application Accepted by Date �~_ xi Area <br /> Pit-or Grout Inspection by Dater 1 Final Inspection by Date ` <br /> Additional Comments:., ._ _ ._'V. ... _ _ a <br /> ❑ Stk 466-6781 ❑ Lodi 3WW21 ❑ Manteca t•823-7104 O Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE.INFO. - AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY . DATE. r, PERMIT"NO.. <br /> + EH 1&24(REV.t i s s) f . <br /> i <br /> EH 34-26 / ` <br /> i <br />