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APPLICATION-FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> r <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 wellipump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address ` - J^V CitLot Size 2 PM <br /> Owner's Name Q&L YJOL S iWi ll;A M 5 Address S �e J 4 UjAl Phone — <br /> Contractor,( 6!tl _Address License No, Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL LI WELL REPLACEMENT ❑ DESTRUCTION ❑ <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 <br /> ❑ Industrial D Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public C1 Other 171 Delta Depth of Grout Seal Type of Grout _. <br /> I i Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Weil Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION I I DESTRUCTION (Na 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 l <br /> 1 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: We9 Foundation Property Line <br /> I a , <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> t FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEFPAGE PITS f I Depth 5 Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> r 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 /> k rules and regulations of the San Joaquin Local Health District. <br /> I 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 must call for all required inspections. Complete drawing on reverse side. <br /> Si ned'i /If�'Yt �� �� �.- Title: �ltJ Date: ~� � <br /> 9 FOR DEPARTMENT-USE ONLY <br /> Application Accepted by Date <br /> Pit or Grout inspection by Data Final Inspection by ate <br /> ( Additional Comments: _Z/1� <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, Silk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*NO. <br /> INFO CASH <br /> 1 <br /> { + EH 13-24(REV.i/H 5) ISq� <br /> _ <br /> r .EH 71-26 �C�'t� <br />