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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED } <br /> (Complete in Triplicate) <br /> in Local Health District for a permit to construct and/or install the work herein described. This application is Joaquin <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 <br /> Application is hereby made to the San Joaqu <br /> Local Health DistrilieVMA.W—,fmdj10—Q <br /> �. / Lot Size PM <br /> Job Address y -57- <br /> / .� 270Phone i(�L <br /> Address <br /> Owner's Name Gs7 kZ7S ,� ode License No.�,. -Phone <br /> Contractor / Address <br /> CTION 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUOTHER C]PUMP INSTALLATION'❑ - SYSTEM REPAIR <br /> DISTANCE TO NEAREST: .SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ <br /> ❑ Manteca Ria. of Well Excavation <br /> Industrial Ll Open Bottom Specifications <br /> Public Type <br /> �4' iclPrivate ❑ Gravel Pack © Tracy yp of Casing - <br /> f`7 Public <br /> I-1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I Irrigation ..Approx.,Depth/ I ! Eastern Surface Seal Installed by LC Ui St7Tj <br /> �� +d C7 N.P. State Work Done <br /> l Repair Work Done 4ir Type of Pump <br /> Well Destruction ❑ Well Diameter --Ln� Sealing Material (top 50') - <br /> t Depth Filler Material [Below 50'I <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i.l REPAIR/ADDITION l I DESTRUCTION I I aNailabpe1within 200 ieetsystem lt`ed it public sewer is <br /> Installation will serve: Residence Commercial_ Other. <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> f PKG. TREATMENT PLT. ❑ <br /> t Distance to nearest: Well Foundation Property fire <br /> Total length/size <br /> LEACHING LINE Cl No. & Length of lines Property Line <br /> FILTER BED CJ Distance to nearest: well Foundation <br /> Number <br /> SEEPAGE PITS l 1 Depth Size Property Line <br /> SUMPS 0 Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> l 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 licens ' signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> i Home any r r li n such man er as to become ubject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fol wing; - certify hat s the pert ce o e ark for w -ch this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of aliforni <br /> The appli nt m st al r11 equir ' in a awing on Sid <br /> Title: � Date: (D 7 <br /> Signed <br /> r EPARTMENT USE ONLY Q <br /> ! Date !�v~ Area <br /> I Application Accepted by v <br /> J Pit or Grout Inspection by Date Final Inspection y <br /> 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 CK RECEIVED BY DATE PERMIT-NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> k INFO <br /> + EH 13.24{REV.1/A 51 <br /> EH 14-26 <br />