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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ._-._..1601- Ei HAZEL T ON AVE., STOCKTON, CA I <br /> Telephone (209) 466-6781 - <br /> PERMIT EXPIRES TYEAR 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. V <br /> Job Address /j / e N ORA®o City aF�r�e � e ' PM <br /> Owner's Name ~7� S Address 9101121- hone y <br /> Contractor r Address O- /YY /4744 License No:-222nPhone <br /> TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT LJDESTRUCTION LJCn <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 k <br /> ❑ Industrial, ❑ Open Bottom ❑ Manteca Dia. of'Well Exca`vatibn Y Dia. of Well Casing <br /> s ❑ Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications <br /> i� l=1 Other F1Delta Depth of Grout Seal Type of Grout❑ Public <br /> I Itrigationi Approx. Depth 1.1 Eastern Surface Seal Installed by - <br />° Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction 1:1Well Diameter Sealing Material atop 501 <br /> Depth Filler Material IBelow 50'1 ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I;i REPAIR/ADDITION DESTRUCTION I 1 iNo septic system permitted if public sewer is i <br /> r available within 200 feet.) <br /> Installation will serve: Residence_T <br /> Commercial_ Other k # <br /> Number of living units: :4 Number of bedrooms ? i <br /> Character rof soil to a depth of 3 feet: 5WAxb V 42 A #K Water.table depth <br /> 1. 1 No. Compartm6nts <br /> SEPTIC,TANK ❑' Type/Mfg Capacity <br /> PKG. TREATMENT PLT. Ell: ;sY. Method of Disposal <br /> t [ Distance-to nearest: Well ' Foundation Property Line <br /> len <br /> Total th/size 5 � <br /> LEACHING LINE IVo. & Length of lines 9 <br /> FILTER BED Distance to_nearest: " Well Foundation _Q,' �Q' Property Line <br /> f f <br /> { <br /> SEEPAGE PITS I 1 Depth Size Number ! <br /> SUMPS r Ll Distance to nearest: Well ' :Foundation Property Line a <br /> DISPOSAL PONDS ❑ r 4 <br /> I hereby certify that I have prepared this application and that the work will cbe done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and'regulations of the San Joaquin Local Health District. ,;i P i <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-contacting signature <br /> certifies the following: "I certify that in the performance-o4-the-work-f or-"iathis permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> i The applicant must Xx <br /> quired inspections,Complete drawing on reverse side. q 1 <br /> Signed X_ �r i' ,t, M Title: �.d�c= Dater <br /> t <br /> OR DEPARTMENT USE ONLY <br /> Application t Accepted by Date Area <br /> f t <br /> Pit or Grout inspection by Date Final Inspection-by- y,�/ Date <br /> i <br /> Additional Comments: <br /> ❑ Silk 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. Box 2409, Stk., CA 95201 <br /> i <br /> FEE AMOUNT:DUE,. AMOUNT REMITTED CK .RECEIVED thy'__ _—DATE—_ PERMIT*NO,-> - --� •� <br /> INFO CASH. .. m- <br /> r <br />� EH 13-24"rREV:tid'5l <br /> i Ef'_IC29 <br /> �� i <br />