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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 ly — Ali" io f �-T+ `jut i &,'ity l„��,”„ � /Zi CdC,L�ot Size PM <br /> Owner's Name LLsf ?t%(k�/�'Q`A Address n hone J <br /> Contractor's Name License No. Phone -�Z <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAI ❑ OTHER El <br /> TO NEAREST: SEPTIC TANK 5� SEWER LINES DISPOSAL FLD. 4'PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial <br /> ❑ Open Bottom Manteca Dia. of Well Excavation 43Dia. of Well Casing <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ /� � Specifications <br /> ❑ Public i <br /> ❑ Other ❑ Delta Depth of Grout Seal Type of GrDe1t <br /> ❑ <br /> Irrigation <br /> ---Approx. ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter <br /> r), � Sealing Material (top 50') <br /> Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence available within 200 feet.) <br /> _ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity Water table depth- <br /> SEPTIC <br /> No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal l <br /> Distance to nearest: Well Foundation Property Line / <br /> LEACHING LINE ❑ No. & Length of lines1 <br /> Total length/size "T <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth P Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ElProperty Line <br /> 1 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 �f <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 1 <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 /> nature <br /> tion laws of C lifornia." <br /> The app' must call for all required ' pections. Compl a drawing on reveride. <br /> Signed ® � ? <br /> tile: `-[ Date: �7 <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted byDate / 3 <br /> Pit <br /> Area f <br /> Pit or Grout Ins � !/ <br /> pection by Date Final Inspection by ` <br /> Date r' <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 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV. 10/83) <br /> EH 1426 3• ¢'�c> p� �� � � �S—� <br />