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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 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 L 16 <br /> City Lot Size PM <br /> Owner's Name �f���� Address <br /> Phone <br /> Contractor mgl-h&�Address 3sV 99TYPE OF Wicense ES ION El L Phone_ Sb <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER El <br /> LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> F1Domestic/Private L1Gravel Pack Dia. of Well Casing <br /> ❑ Tracy Type of Casing <br /> M Public ❑ Other ❑ DeltaSpecifications <br /> Depth of Grout Seal <br /> I I Irrigation __Approx. Depth I I Eastern ----- <br /> Repair Work Done 11T Surface Seal Installed by <br /> Type of Grout <br /> Type Pump H.P. State Work Done_ <br /> Well Destruction ElWelll Diameter <br /> Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION k.� 'r -- <br /> RUCTION I I (No septic system permitted if public sewer is }� <br /> Installation will serve- Rsidence Commercial_ Other <br /> available within 200 feet.) <br /> Number of living units: Number of bedrooms :�­ <br /> Character of soil to a depth of 3 feet: C �/ t�.bi4 I'V1 <br /> SEPTIC TANK ElType/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation Property Line <br /> LEACHING LINE tp­1406. & Length of lines <br /> FILTER BED ❑ Distance to nearest: WellT taL length/size <br /> Foundation / Property Line <br /> SEEPAGE PITS I`T Depth <br /> Size Number <br /> SUMPS Ll Dist to nearest: Well - <br /> DISPOSAL PONDS ❑ FoundationProperty Line <br /> (ZU/ ` <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 Diltrict. <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." Contractor's hiring or sub-contracting signature <br /> certif a following: "I certify that in the performance of the work for which this permit is issued, I shall employ <br /> tion laws o fitornia." p p y persons subject to workman's compensa- <br /> tion <br /> appfican mu all r al equ�dmctio s. om le te wing o verse sid . <br /> Signe ��y H <br /> itle: — /b �-� <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ----- -- L 1 <br /> Date (J Area r / <br /> /Dirt or Grout Inspection <br /> t,J ate'L�–?4 Final Inspection b�Tr9 Date <br /> Additional 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 NS <br /> AMOUNT DUE <br /> INFO AMOUNT REMITTED CK RECEIVED BY <br /> CASH DATE PERMIT-NO. <br /> ♦ EH 13-24(REV.ties) - <br /> EH 14-26 - gr <br /> / C71Z <br />