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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 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. 1862_for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.' C -�- <br /> I Job Address City � j ^ Lot size PM <br /> Owner's Name 7 C Address Phone <br /> Contractor L_� KLt h14ILI— Address _ J 0 Uft 4 lLicense fio. ! 3d?%, Phone ,56 <br /> TYPE OF WELL/PUMP: ;I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 'SYSTEM REPAIR-17 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 ❑ Gravel Pack ❑ Tracy Type of"Casing— Specifications <br /> M Public ❑ Other ❑ Delta . Depth of Grout Seal,- Type of Grout UT <br /> I I Irrigation _.-Approx. Depth t I Eastern Surface Seal Installed by _ VV�r <br /> Repair Work Done ❑ Type of Pump 4 H.P.' -State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing'Matenal Itop 50'iT =res <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f AIR/ADDITION i 1 DESTRUCTION i I (No septic system permitted if public sewer is <br /> fI available within 200 feet.l <br /> r Installation will serve: Residence commercial Other <br /> F Number of living units: 4_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Q � = --- Water table depth <br /> b �,,.,._.-. <br /> SEPTIC TANK ❑ Type/Mfg C-F]I*Ic5nLIC-1 Capacity__/77�ZC) No. Compartments <br /> k PKG. TREATMENT PLT. ❑ i Method of Disposal <br /> Distance to nearest: 11Vell Foundation 1 Pro erty.Line <br /> LEACHING LINE &.--No. &Length of lines , s Total length/size " <br /> 1 -740 <br /> FILTER BED El Distance to-nearest: Well Foundation-16 Property Line s <br /> SEEPAGE PITS I 1 Depth} Size _ Number r <br /> i SUMPS lu stance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Llt U S{� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county'6rdinances, state laws, and <br /> 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."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 /> j tion la of Californi . <br /> IF The applicant t call for II re ire i s ction . o plate drawing on reverses e. <br /> �1 Q <br /> Signe Title: _�� -' J Date: —/o —g L? <br /> F FOR DEPARTMENTUSE ONLY <br /> r . <br /> Application Accepted by � Date l��Araa <br /> Pit or Grout Inspection by y Date Final Inspection by aa �� Date ✓ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 El Tracy 835-6385 <br /> I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> FEE <br /> I <br /> F CK f <br /> INFO AMOUNT DUE 'AMOUNT-REMITTED '" ' CASH "RECEIVED BY` DATE PERMIT'NO <br /> ♦.EH 13-241REV.v/H51 <br /> } EH 14-2a <br />