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4f/I_ � \ S <br /> LLss t <br /> a/ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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 4Z cop , <br /> "� <br /> City Lot Size—7—/ pNl_ <br /> Owner's Name ?LdAdl. Address Fp <br /> Phone <br /> 4 <br /> Contractor's Name f v►-License No. S�5s <br /> a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I- DESTRUCTION ❑Phone 2 <br /> PUMP INSTALLATION�,�r SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �_ SEWER LINES DISPOSAL FLO. 456 *-*PROP. LINE 4;U' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Ind trial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S <br /> 13 Public El Other Specifications <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Dep ❑ Eastern Surface Seal Installed by <br /> Repair Work Done El Type of Pump H.P. �_ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth_ Filler Material (Below 50') <br /> REPAIR/ADDITION ❑ DESTRUCTION LJ (No septic system permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ <br /> installation will serve: Residence_ Commercial— Other available within 200 feet.) S <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Z <br /> SEPTIC TANK ElT - Water table depth <br /> Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS Number <br /> ❑ 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 <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 must call for all required inspections. Complete drawing on reverse side. <br /> ——*-fJ-c r7 <br /> Signed }L�_ - Title:� , <br /> Date: <br /> FOR DEPAR ENT USE ONLY <br /> Application Accepted by Date <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by 7; > Date a2 i rte_ <br /> Additional Comments: <br /> ❑ Stk 466 6781 01 Lodi 369-3621anteca 823-7104 Ll Tracy 836-6385 <br /> Applicant- Return all copies to: Environmental Heal h Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> RECEIVED BY DATE PERMIV No. <br /> I <br /> + EH 13-24(REV.10/83) <br /> EH 1426 ..� �� Li.,. G`'O !L% <br />