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r »'J <br /> APPLICATION FOR PERMIT ; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZE'1 TON AVE., STOCKTON, CA <br /> Telephorle (209) 466-6781 DEC 2 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ('cls?,,:,,"•i v�':?V����.` <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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local health District. <br /> Job Address —!A """te^ City Lot Size PM <br /> Owner's Name Address L© �� �%� _4141;�Ad-eO�Qhone <br /> Contracto Address 0 Llo • I OLicense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION X 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 D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public Ll Other 11 Delta Depth of Grout Seal Type of Grout _. S <br /> I I Irrigation --Approx. Depth l 1 Eastern f urface Seal Installed by - O <br /> Repair Work Done ❑ Type of Pump ,4.L�� H.P. �� State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 54') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l'1 REPAIR/ADDITION i.l DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> P <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil.to a depth of 3 feet: - Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity z 'No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal " <br /> k a <br /> Distance to nearest: Well Foundation Property Line <br /> length/size <br /> "° '~ <br /> LEACHING LINE ❑ No. & Length of lines °" ­A Total len 9 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS El <br /> -.. <br /> 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 /> iuli`s and regulations of the San Joaquin Local Health Di§trict. r <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, 1 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 /> The applicant for all required inspections. Complete drawing on re erre side. <br /> 01 -60r <br /> Sign X Title: r Date:/,t <br /> F E A T E USE ONLY p <br /> Application Accepted by Date,/ .2' ��" Area 52'!�_ - <br /> Pit or Grout Inspection by Date Final Inspection by - Date 1 <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6386 ` <br /> k Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA.95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CKO CASH RECEIVED BYE' DATE PERMI'T'NO. <br /> INFO J <br /> +, <br /> EH 1320(REV.1/n 51 3 •��^ 1! l--1 �q <br /> EH 14-26 1 <br />