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APPLICATION FOR PERMIT 10: <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> 1 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 c d/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 862 for well pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. yl <br /> Job Address Soa `����-� City t�' Lot Size PM <br /> Owner's Name 1 ' `���g '\ \ Address'�C>, \+-- �� Phone `0�� <br /> ]JH _ r� y6G� �S9 <br /> CentractorCa �icense No.I/`1�7 �o Address " �" ' �� ry� Tc �°�� Phone <br /> TYPE OF WELL/PUMP: NEW WELL fl WELL REPLACEMENTA DESTRUCTION <br /> PUMP INSTALLATIIOON ''& SYSTEM REPAIR ❑ OTH11 �R 0 <br /> DISTANCE TO NEAREST: SEPTIC.TANK _.,_ 6 SEWER LINES DISPOSAL FLD PROP` LINE <br /> " FOUNDATION LLI AGRICULTURE WELL OTHER WELL . PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT[ NS �( <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia" of Well Excavation Dia. of Well Casinj <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing Y G I Specifications <br /> � 4 <br /> FI Public (7 Other ❑ Delta Depth of Grout Seal Type of Grout R r CCS <br /> I I Irrigation _Approx. Depth I I Eastern Suriace Seal Installed by - <br /> : A <br /> Repair Work Done ❑ Type of Pump H.P. 00State Wo r D ne <br /> tt <br /> Wel! Destruction � Well Diameter � Sealing Material (to T <br /> Depth `filler Material (Belo+m <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION l I (No-septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: ResidenCommercial Other <br /> Number of living units: N2Eberof 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. ❑ Method of Disposal <br /> ` Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size y <br /> FILTER BED D Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire _ Number <br /> SUMPS D 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, stale laws, and <br /> rules and regulations of the San Joaquin Local Health District. 1. <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 /> 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 /> aiThe applican �s c u for all required inspections. Complete drawing on reverse side. <br /> Signed X _ Title: <br /> O��W IN Q.- Date:` ` <br /> 'mow FOR DEPARTMENT USE ONLY f} <br /> i Application Accepted by Date "1`Z _ Area <br /> Pit or rout spection by ate Final Inspection by Date V' ` <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, Sik., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO <br /> INFO CASH <br /> a EH 13-24 MEV.t/H 51 <br /> EH 14-25 <br />