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�a <br /> APPLICATION FOR PERMIT �� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601-E. HAZEL TON 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 ©�r �` 1 City 4Z Lot Size PM <br /> Owner's Name (L4 '� A-c—, Address �� a&4_,644 - Phone3 3 V,.-11-9 <br /> Contractor Address(o (. N License No/4 )`3 23 PhonAk94 SX4f <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 /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ 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 <br /> CY11rrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done El _1(cType of Pump , H.P. State Work Done r J <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 Q <br /> Depth..___ filler Materiat4l3elow-Wi _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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'- <br /> depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity partments <br /> PKG. TREATMENT PLT. ❑ thod of Disposal <br /> �_ItuNu <br /> Distance to nearest: Well Foundation - ,Property UrAnr'R 40!111 `lZJ8 <br /> 9 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Prop" NMFNTAI_HEALTH <br /> PERMIT/SERVICES <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS n a Well Foundation Property Line <br /> D1SPQSALRONDS ❑ <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 applica t must all for all r uired inspections. Complete drawing o reverse side. I <br /> Signed X P�� 71_--Y`/ le: �1It ' I Date: '7'", ,a._ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> 10 ) <br /> Pit or Grout Inspection by Date Final Inspection by Date 6''6/ 7 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63855 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT`NO. <br /> + EH13.24(REV.1/95) <br /> EH 14-26 25 l <br />