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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA <br /> Teleph6ne (209) 466-6781 <br /> PERMIT EXPIRES 17 YEAR'FRO M 'DATE,ISSUED <br /> (Complete in Triplicate) <br /> A <br /> Application is ereby m de 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 RtIles,and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address vad city Z Lot Size PM <br /> Owner's Name a__4,W, Address Phone. <br /> Contractor AddressLaA__6.P,,&4abe- License fVo. Phone '2_'3e2-_4Y6P-20:U�P_ <br /> TYPE OF WELL/PUMP: NEW WELL 0' WELL RtPLACEMENT E71 DESTRUCTION D <br /> PUMP INSTALLATION 0 SYSTEM REPAIR_I~ OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FILD.— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial 0 Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> EJ Domestic/Private El Gravel Pack Ll Tracy Type of Casing Specifications <br /> 0 Public 0 Other El Delta Depth of Grout Seal Type of Grout <br /> El Irrigation ---Approx. Depth 11 Eastern Jurface Seal Installed by <br /> Repair Work Done ff Type of Pump H.P. State Work Done <br /> Well Destruction Ll Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 601 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION C REPAIR/ADDITION C1 DESTRUCTION C] (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will-serve: Residence— Commercial— Other <br /> Number of living unit's:1-4 Number of bedrooms <br /> Character of soil to a depth Of 3 feet: Water table depth <br /> SEPTIC TANK E], ,Typp/Mfg. Capacity No. Com.partrnents-',,.-.-' <br /> PKG. TREATMENT PLT. D _�!Methocl of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE _C -No. & L&4t6of lines -Total length/size <br /> FILTER BED El Distance to nearest: Well Foundation— Property Line <br /> SEEPAGE PITS C Depth Size Number <br /> SUMPS El Distance to nearest: Well Foundation— Property Line <br /> DISPOSAL PONDS F7 <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."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." <br /> The applicant ust call faoll required inspections. Complete drawing on reyDrse side. <br /> Signed Title: C�1� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection Date Final Inspection Date <br /> Additional Comments: <br /> El Stlk 4W6781 0 Lodi 369-3621 11 Manteca 823-7104 0 Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9=1 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV,Iles) i. <br /> S <br /> EH 14-26 Jiskii— <br />