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APPLICATION FOR PERMIT <br /> l SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209} 466-6781 <br /> PERMIT EXPIRES 1 YEAR.FROMYDATE'ISSUED #Y " 4, <br /> .. r`v,?,,� .f,�--mak-.: ._$.'.t1!„ G` a •.; :Y ��t. <br /> .k r,. (Complete in Triplcate). <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereindekribed.'TMs: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 /> I Local Health District.. <br /> 1 if ..f. iV.v �' fr�`v t1�l�..Y✓ <br /> Job Address PM <br /> _. City Lot Size <br /> Owner's Name t1 -Address Z /!! 'phone <br /> Contractor's Name 9J� i�L l <br /> t �1— License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP 11SISTALLATION ❑ SYSTEM REPAIR E< 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 /> ElIndustrial ❑ Open Bottom ❑ Man#eco Dia, of Well Excavation <br /> 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 /> ❑ Irrigation —Approx.i Depth ❑ Eastern Surface Seal Installed by k <br /> F <br /> Repair Work Done ❑ Type of Pump,,;,_ H.P. State Work Done Z <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 /t._ <br /> * Depth Filler Material (Below 501 _ `� <br /> TYPE OF SEPTIC WORK:�NEW,INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ {No septic system permitted if public sewer is v <br /> `, available within 200 feet.) �] <br /> Installation will serve': Residence Commercial Other �a <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. ❑ 1 Method-of Disposal ' <br /> i. <br /> Distance to nearest: Well r� Foundation Property Line I <br /> 'LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> .FILTER BED ❑ Distance to nearest: Well <br /> Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> - 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 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 <br /> 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 mut call far all required inspections. Complete drawing on rev . side. } <br /> Signed + `J Ile— Title: X,1/1 r <br /> Date: <br /> _ FOR O ARTMENT USE ONLY <br /> Application Accepted by { `p9 q <br /> W Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date r r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi .369-3621.1 ❑ 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 /> INFO AMOUNT DUE AMOUNT REMITTED C eASN RECEIVED BY DATE. PERMIT"NO. <br /> + EH 13-24 MEV.10/83) rLJ� 1 /��/} 3-7L7 Q <br /> EH 14-26 1 70 f �V[J �"O.�' �� '51 <br /> i <br />