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t <br /> APPLICATION FOR PERMIT <br /> `\ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. H_AZ_EL T ON AVE., STOCKTON, CA <br /> ,,..,. •, .. -__ Telephone t209l._466-6781 <br /> /PERMIT <br /> t Fx�QflES­-1- (-EAR FROM DATE ISSUED-- <br /> Applicationis 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 ? ✓ City ®G Lot Size ZO 0PM <br /> Owner's Name �/ M�S ��Pr1C� Address � EPhone �✓ _ <br /> Contractor ��e_ 5 (� Address License No. Phone_ <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 /> ('1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation _..Approx. Depth l I 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 50') <br /> Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 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 depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: 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 /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS ❑ 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 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."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." <br /> The applicant st call for all re fired ' spec ns. Complete drawing onrr'evverse side. <br /> Signed X Title: (;1, aI, Date: <br /> OR "TMENT USE ONLY �t fv� <br /> Application Accepted by w ..n , JA ..t _�. Date Area <br /> Pit or Grout Inspection by ,p Date- Final InTtion by6.,�/ p�o- Date WL2r/,rf <br /> Additional Comments: _ ��yS t Z Y ►r 1 t t-� `-Y O �l <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 95201 <br /> FEECK 4- <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY �DATE pPEE}RMIT/NO.. <br /> a,EH13.24(REV.t/x 51 <br /> oz <br /> 26 <br /> EH 14- J <br />