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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH,DISTRICT <br /> 1601 E. HAZE T ON 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 fora 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. p ,� <br /> PO <br /> -17 <br /> Job Address �^ City Lot Size PM <br /> Owner's Name 1�/p`a ti' dnJ --Address- Phone <br /> Contractor;C +_- Address. �.RDx S ,2f37 License No.- Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ SWELL REPLACEMENT E] 4 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ "� SYSTEM-REPAIR (�.w�.y _ 4 OTHER ❑ ] <br /> DISTANCE TO NEARES TANK SEWER-LINES - 1 DISPOSAL�FLD. PROP. LINE <br /> FOUNDATIO AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL A CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Wall Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casrn Specifications <br /> F1 Public ❑ Other Cl Delta Depth of Grout Seal----, Type of Grout <br /> I I Irrigation ---Approx. Depth i 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.50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 13 DESTRUCTION I I (No septic system permitted if public sewer, is <br /> " available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other Z4_ <br /> Number of living units: Number of bedrooms _ --- ___•h <br /> Character of soil to a depthpf 3 feet: Water table depth <br /> S-E 6Ti 1K Type/Mfg C— Capacity J -yJ o. Compartments <br /> PKG, TREATMENT PLT. ❑ Merthod of Disposal + <br /> Distance to nearest: Well Foundation Property Line. YL�TY� i1�� <br /> LEACHING LINE ❑ No. & Length'of lines Total length/sizer <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I f Depth Size— Number I <br /> SUMPS ❑• Distance to nearest: Well Foundation Property,Line <br /> DISPOSAL PONDS ❑ ttt( <br /> I hereby certify that I have prepared this application and thai 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-D1iltrict. ---- <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 i uch manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the follow. "I certify that in the performance of the work for which this permit is issued,I shall employpersons subject to workman's compensa- <br /> tion laws of Calif a." <br /> The applicant us call for all requi pection omplete drawing on reverse side. ` <br /> ` C3 <br /> Signed X ��Title • F - - /��1 t�, Date: '^/ <br /> oe­ <br /> FOR DEPARTMENT USE ONLY <br /> Applicatio Accepted by Y Date 5-1 `' Area <br /> Pit or Grout Inspectio Date Final Inspection by } Date <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 CASH- RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +.EH13-2 (REV.+/N 51 <br /> EH 10266 ! r <br />