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I <br /> APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t fff <br /> F 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r (Complete in Triplicate) <br /> I Application is hereby made to•tha San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made incompliance with San'IJoaquiri County Ordinance No.549 for'sewage or No, 1062 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 1.3 O 3 City Lot Size 1ST X �U 'PM <br /> i <br /> ! Owner's Name j�a ea K`t 1►t•a - <br /> Address <br /> = I o i'a u Phone y�6 <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ;, <br /> DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> iFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS V <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> k ' ❑ Industrial' ❑ Open Bottom ❑ Manteca—---Dia.-of-Well of-Well Excavation- --- "'" Dia. of Well Casing <br /> 4 ❑ Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public LI:Other ❑ Delta Depth of Grout Seal f l Type of Grout <br /> 11 irrigation -LI -Approx. Depth ❑ Eastern Surface Seat Installed by <br /> Repair'Work Done ❑ Type of Pump H.P. State Work Done I <br /> f Well Destruction El Well Diameter Sealing Material (top 501 <br /> } Depth Filler Material (Below 501 <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION.El (Nd septic system permitted if public sewer is <br /> available within 200 feet.) <br /> I Installation will serve: Residence Commercial' Other <br /> Number of living units: Number of bedrooms <br /> r <br /> Character of soil to a deptAi of 3 feet: 4 Water table depth <br /> SEPTIC TANK ❑ T ' <br /> � ype/Mfg � Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size 1 <br /> FILTER BED ❑ i Distance to nearest: Well Foundation Property Line <br /> / 1 <br /> SEEPAGE PITS ❑ ; Depth Size Number '"''- <br /> _ � <br /> SUMPS ❑ I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ . . s <br /> F 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 /> F rules and regulations of the San Joaquin Local Health District. <br /> Home owner'or licensed agents signature certifies the following: "I certify that in the performance of the work for which thispermit is issued, I shall not <br /> employ any person in such manner as to-become subject-to-workman's compensation laws of Califamia`."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." iIN, l <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X �� � , �L- --� Title: Date: �7 <br /> FO EPARTME USE ONLY <br /> s Application Acc2, <br /> epted by Date Area <br /> Pit or Grout Inspection by I� ate Final Inspection Date~ ✓ <br /> l Additional Comments:_ At Zls <br /> ❑ Stk 466-6701 ❑ Lei 369-Al ❑ Manteca $23-7104 ❑ Tracy 835-6385 <br /> i Applicant- Return all copies 4o: Environmental Health Perrnit/Services 1601 E. Hazekon-Ave., P.O. Box 2009, Stk., CA 95201­_.FEE <br /> 1 INFO AMOUNT DUE AMOUNT REMITTEDCASIT RECEIVED BY DATE PERMIT"NO. <br /> + EH13-24IREV.1/85) � T- <br /> EH 1428 <br />