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APPLICATION FOR PERMIT <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> " Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED n <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. 1662 for well/pump and the Rules and Regulations of the Sari Joaquin I <br /> r Local Health District. *�-• 0 1 �, / r <br /> 7o L fj"T4 Lot Size PM F� <br /> Job Address ► City <br /> Owner's Name �7!�!+ r ,+, 7� address 46 �� — Phone 4 s <br /> i <br /> Contractor x Address License No. Phone <br /> TYPE OF WELL/PUMP' ti NEW WELL ElWELL REPLACEMENT ❑ DESTRUCTION 11 t <br /> •PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WE PITS/SUMPS # <br /> INTENDED USE TYPE OF WELL PROBLEM ARE NSTRUC FICATIONS <br /> f] Industrial ❑ Open Bottom 7-1MantecaD' xcavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F-1 Public ❑ Other 171 a Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ----Approx. D ❑ Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of p H.P. State Work Done <br /> i. <br /> Well Destruction ❑ Diameter Sealing 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 /> A r - : available within 200 feet.) <br /> installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms �_ <br /> I Water table depth, M4, /ice <br /> w Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ^ <br /> PKG. TREATMENT PLT. <br /> LJ of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> — <br /> ` <br /> s� 4 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> Number <br /> SEEPAGE PITS 71Depth Size ' <br /> h <br /> a e' <br /> SUMPS _ ....LlPra Distance to nearest: Well .� Foundation ' } Property Line <br /> DISPOSAL PONDS ❑ - F _ - " <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."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."The licant t ca11 for all requiredinsp-ctions:'Complete drawing on reverse side. S <br /> T°itlDate: <br /> <3 <br /> f Signed X <br /> i -T•-FOR-DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date rZ 4 Area v <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: <br /> Allo <br /> I ❑ Stk 466-6781 ElLodi 369-3621 ❑ Manteca 823-71104 E3 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 /> FEE AMOUNT DUE AMOUNT REMITTED C -RECEIVED BY DATE ;PERhM11T'NO. <br /> INFOEH 13-24 iREV.7/x s1 1 �, �� _ <br /> EH 14-29 r ,, <br />