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APPLICATION FOR PERMIT . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.TON AVE., STOCKTON, CA AUG 199 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES ARFpIOMDATE ISSUED <br /> (CompleteTriplicate) <br /> ep�hty rv]SER�`+ff,�! f,^ <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. �j <br /> Job Address S / ity Lot Size PM <br /> tFSu/VL Co <br /> Owner's Name Address ` Phone <br /> 11 � <br /> (?,., 01—�� _ <br /> Contract JLe. Address O �4cense Nv. c�194� - Phone _;2_R_1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ _WELL REPLACEMENT [I DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION 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 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Public F] Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation _Approx. Depth I 1 Eastern Surface Seal installed by _ <br /> Repair Work Done X Type of Pump /&g" H.P. MAA-A� State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filter Material (Below 5111 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is �} <br /> available within 200 feet.) <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. ❑ 1. <br /> 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 I I Depth Size Number <br /> SUMPS L1 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t c for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> MEN USE ONLY <br /> Application Accepted by M�7 <br /> Date / .- Area �f <br /> Pit or Grout Inspection by Date Final Inspection by Date Q <br /> Additional Comments: <br /> ❑ Stk 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 2009, Stk., CA 95201 <br /> FE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> +.EH 13-24(REV.1/H sl ?s Lr! <br /> EH 14-2f3 nl <br /> U 7�l a,7 4V <br />