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- A' NI W r0 1. 0-i �tAsv4y <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT C1..€`k ¢o>r b, L:u£ <br /> t 1601 E. HAZELTON 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. ^, <br /> Job Address z q � �� C 1k,S f }— Cityof ize S /V OPM <br /> rr_ ��• .__..- r� ,rte _. -- ��w .._ .. <br /> Owner's Name 'Z-4, 4- Address ��`� Phone <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: SEP TANK SEWER LINES DISPOSAL FLD. PROP LINE <br /> FOUNDATIO AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL CONSTRUCTI IFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca il ell Excavation.- -. Dia. of Well Casing , <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other to Depth of Grout Seal g Type of Grout <br /> ❑ Irrigation �Approx. ❑ Eastern Surface Seal Installed by f <br /> Repair Work Done ❑ Type a mp H.P. State Work Dane s <br /> Well Destruction ❑ I piameter" ' Sealing Material (top 50') s <br /> Depth Filler Material (Below 50') {} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION f (No'septic system permitted if public sewer is <br /> T# available within 200 feet.) <br /> e <br /> Installation will serve: Residence— Commercial� Other »-a <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- ❑ Method of Disposal <br /> Distance toy nearest: Well Foundation Property Line <br /> tA <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well I Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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 I <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 fallowing: "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." <br /> The applicant must call)f�r-al requ d inspecbi ). Complete drawing on revn_&A_ryNA_-A.de. <br /> Signed t/ Title: _ Date: <br /> F O USE ONLY y <br /> Application Accepted by Date Area I <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: rip, <br /> ❑ Stk 466-6781 ❑ Lodi369-3621 ❑ Mante 823-7104 ❑ Tracy 835-6385 j <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE t PERMIT'll <br /> INFO CASH <br /> + EH 13-24(REV.tiiN5) Q4 ^'7 9 <br /> EH 14-25 / [3 Z7 <br />