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I <br /> ' nF} APPLICATION FOR PERMIT <br /> A0 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 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 /> o <br /> Job Addres +_--�1Ji-rte! City Lot Size PM ` <br /> 07 <br /> Owner's Name ,in1i � Addressy -� Phone ? <br /> �,]] / 4 E <br /> Contractor c 1;IZ Address ! L'^'�L ense No.JO-3f 6 Phone y <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ?SWELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 y,,Dia. of Well Excavation Dia. of Well Casing <br /> >(-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of.Casing Specifications <br /> FI Public ❑ Other 11 Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation _..Approx. Depth I-I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump..�� H.P. �j� 1 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50:{ _A <br /> r <br /> Depth Filler Material (Below 50T' _� t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is rill <br /> available within 200 feet.) <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: <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacit 11,11 No. Compa`rtrtmen <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Pr, rr Ip�t�` <br /> LEACHING LINE ❑ No. & Length of lines ' Tot i \` <br /> FILTER BEd ❑ Distance to nearest:. WeII Foundation <br /> SEEPAGE PITS I I Depth Size ' Number <br /> SUMPS L Distance to nearest: Well zFoundation Property Line <br /> DISPOSAL PONDS ❑ <br /> J ' <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 Dihtrict. �.. <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 /> The applicant must caU for all requ' d inspections. Complete drawing on verse side. ... <br /> e <br /> Signed Title: �r _- Date: <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by �- Date y Area 2r 6 <br /> Pit or Grout Inspection by Date_..ti ' Final Inspection by Date <br /> / v <br /> Additional Comments: <br /> ❑ Stk 466-6781 LJ 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 /> FEE1 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'NO. <br /> ­EH 1344{REV.I/M5f 3� ,i : � 7 � g�i� '-7 <br /> EH 14-26 O f O <br /> { <br />