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OW3 OS <br /> APPLICATION FOR PERMIT 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMMIT E)(PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heteby 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 sill,7V g A41 1 m RA City j"12 Lot Size PM <br /> Owner's Name'' Qg Address `�spn he-, &R Phone 371251-1 <br /> Contractor Address 715 £.A�u�(�Q License No. 39 lS�Phone S39 '30 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑• <br /> DISTANCE TO NEAREST: SEPTIC TANK -1. SEWER LINES DISPOSAL FLD. PROP. LINE30-0 <br /> FOUNDATION AGRICULTURE WELL —,—'OTHER WELL PITS/SUMPSt7 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 511hf <br /> El Industrial �f'.Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 44-9h=tk T_ Specifications L 014 <br /> Fl Public Cl Other Cl Delta Depth of Grout Seal too Type of Grout___qZ& —_. <br /> I I Irrigation ---Approx. Depth I 1 Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump • H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 S. <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> r <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to neares Well Foundation Property Line <br /> LEACHING LINE ❑ .No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> U <br /> SEEPAGE PITS I I Depth S 16e, 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 Di§trict. <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:"1 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 Calif rnia." <br /> The applicant s 1 II re fired " s. Complete drawing on reverse side. <br /> Signed Title: �./)7 Date: <br /> D TMENT USE ONLY <br /> Application Accepted by Date a` Area <br /> Pit or Grout Inspection by— �L Date Final Inspection by Date <br /> Additional Comments: <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 200, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. <br /> a.EH 13.24 IREV.1/85) INFO <br /> EH 14.26 <br />