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APPLICATION FOR PERMIT <br /> �0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heieby 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 <br /> J e Cit Lot Size l°FL PM <br /> Owner's Name W-[z_y Yr IG�d[�i�t► Address W " ^ Phone <br /> ~� .ZCS License No,,l-?o Z Phone �v 7 <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES. DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 71 Public ❑ Other Fl Delta Depth of Grout Seal Type of Grout <br /> f 1 Irrigation _..Approx, Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> t Depth `- Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence r� Commercial_ Other. 11.. <br /> Number of living units: —IL Number o bed`rooms :; <br /> Character of soil to a depth of 3 feet: �0#Zf-k _ Water table depth <br /> SE?TIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 . Method of Disposal <br /> V, <br /> Distance to nearest: Well ;,Foundation Property Line <br /> a , <br /> � J [ <br /> LEACHING LINE CNo. & Length of lines �G',/ `J I Total length/size � V <br /> FILTER BED ❑ Distance to nearest: Well 7�i / ,Foundation t°? Property L'+ne <br /> SEEPAGE PITS i I' Depth Q r Size ._ _I I'j. Number <br /> SUMPS <br /> ) <br /> SUMPS 64--Distance to nearest: Well—tt'� Foundation�__._ Property Line -gip I <br /> DISPOSAL PONDS ❑ r � <br /> I 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 /> I rules and regulations of the San Joaquin Local Health Di§trict. x <br /> E Horne 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 comp ns <br /> tion laws of California." <br /> The applicantust call fora requ d inspections. Complete drawing on eyerse side. <br /> Signed X ___ Title A)A Date: <br /> t i yFOR-DEPARTMENT USE ONLY <br /> jj �f <br /> Applicatio Accepted by Date S- Area <br /> Rif/or Za ou spefon by /� Date x final Inspection by .. Dat,�� <br /> Additional Comments: <br /> ElI Stk 466.6781 / Q Lodi 369-3621 '❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i< <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +.EH 13.24{pEV.F/K 51 � /'] /34 <br /> I{ <br /> EH 1426 C� <br />