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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 C" , <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED .c , <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 i <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.e.. .. , �� 1 I 1 <br /> Job Address City X7^e /�4 Lot Size PM IIII <br /> " - H <br /> /rl- _ /�YLL � E Address' OCU� Cf — Phone <br /> Owner's Name_� . <br /> Contractor Z L? ' Address ` License No.�Phone S70 <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 Q c <br /> -FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS W i <br /> INTENDED,U,SE �^yTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ElIndus'trial �� O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 4 <br /> ❑ Irrigation _ _Approx. Depth. _❑ Eastern «- Surface Seal Installed by <br /> Repair Work Done ❑ {Type of Pump - v H.P. State Work Done <br /> Well Destruction ❑ :Weil Diameterl Sealing Material (top 501 <br /> Depth .=- -Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Lli.REPAIR/ADDITION El DESTRUCTION o septic system permitted if public sewer is <br /> Y - available within 200 feet.) <br /> Installation will serve: Residence Commercial Other ' <br /> Number of living units: Number of bedrooms a <br /> Character of soil to a depth of 3 feet: F Water table depth <br /> SEPTIC TANKTypelMfg 1_ ' Capacity, No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> i <br /> Distance to nearest: Well Foundation Property Line <br /> I , <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> y ) <br /> SEEPAGE PITS ❑ Depth Size ` Number <br /> SUMPS ❑ Distance to nearest: Well Foundation 'Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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." i <br /> The applicant must call for all wired inspections. Complete drawing on 777 <br /> ZA_a� <br /> O -] <br /> Signed Title: Date; . 3- 16 v ! <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area�� <br /> I Date'!z-c� <br />` Pit or Grout Inspection �J ate C, J Final Inspectio y <br /> Additional Comments: ��Y i V_S 4 �r <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520V <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO / 2 ��J <br /> + EH 13-24 raEV.s/a 57 � � ,}�.• �v' �g / <br /> EH 14-28 - - <br />