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APPLICATION FOR PERMIT <br /> w _ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAALTON 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.1861 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. j/.� L. . <br /> Joh Address <br /> 70 v :1 `I*�• l/ ' t3 C L City C Lot Size PM <br /> Owner's Name cZ L cKLI � Phone <br /> t11'L'ifl Address <br /> Contractor Address ~2`7 ��'1a 11aLE ense No. P / Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE ENT X DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ZA=,'+ SEWER LINES DISPOSAL FLD._,K3nZPROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r <br /> ❑ Industrial ❑ Open Bottom C! Manteca Dia. of Wel[ Excavation Dia. of Well Casing <br /> X Domestic/Private >5-Gravel Pack .Tracy Type of Casing �r�r Specifications <br /> / <br /> ❑ Public 11 Other CI Delta Depth of Grout Seal 0 f '� Type of GI? <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by f <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well (Destruction ❑ Well Diameter Seating Material (top 501 ' <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) I <br /> Installation will serve: Residence_ 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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <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, 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 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 applican st call for all required 'inspections. Complete drawing on rerse side. f <br /> hrz <br /> Signed �L 4L /cam- � Title: � z Date: j/ <br /> r FQR _DEPAR MIENT E ONLY 7 <br /> 02 <br /> Application Accepted by <br /> Z 24 t ,j'CG Date .5�G 41 Area <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection,by�7 _ <br /> Additional Comments: ! "K�" � ` [ 44C <br /> ❑ Stk 466-6781 ❑ Lodi 369.3511 ❑ Manteca 823-7104 ❑Tracy 835 6385 <br /> rm <br /> Applicant- Return all copies to: Environmental Health Permit/Se 1601 E. Hazekon Ave., P.O- Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> WINFO <br /> ♦ EH 21(:REV.m e 5t (� • O o O'er r RrS O <br /> C--7 <br /> EH t�-26 <br /> t <br />