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f4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601'E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES 1 YEARTROM DATE ISSUED <br /> �✓ (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct aind/or install the work herein described. This application is <br /> made in compliance with San Joaquin Cou-9ty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health D' ict. d� j r0 <br /> ovey <br /> &.r6e & A, <br /> i ;) <br /> Job Addre.(. Cityta Lot Size PM <br /> Owner's Nam 01dress Phone <br /> Contractor's Na License No. CJ Phone �-a✓�' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - -N OTHER.,C-I— <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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal' Type of Gout <br /> ❑ Irrigation _—Approx. Depth ❑ Eastern Surface Seal Installed by ' <br /> a <br /> I <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 } <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) g <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: Wate able depth j f <br /> i SEPTIC TANK ❑ Type/Mfg�' 1 Capacity No. Cornpartments <br /> f PKG. TREATMENT PLT. ❑ Method of Disposal <br /> 1 Distance to nearest: Well 'Fbuh2rafiBr a Property Li e, 1 A <br /> i _ t <br /> l LEACHING LINE ❑ No. & Length o lines — - - I Total length/size *'� f <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' <br /> SEEPAGE PITS ❑ Depth _Size Number <br /> SUMPS ❑ Distance to nearest: Well � �r,Foundation i 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, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> HWC,flur <br /> icensed ent'a signature certifies theJollowing:-"I'certify that in the performance of the work-for which this permit is issued, I shall not <br /> F emjin <br /> manner as to become sii 'ect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cecertify that in the pert a of the work for which'•this permit is issued, I shall employ persons subject`to workman's compensa- <br /> tiof f.. g <br /> Thall for all re amp a drawing o e side. l ° <br /> Si Titl Date: zwq- Of <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by s Date Area <br /> F <br /> Pit or Grout Inspection by r ,,Date -`- Final Inspection by 1 � Date <br /> �6� <br /> Additional Comments: P e V-1..1 4j- <br /> El - <br /> ❑ Stk' 466-6781 ❑ Lodi 369-3621 © Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. <br /> INFO CASH <br /> + EH 13.24(REv.1018313 S Q -7/1* S:!? <br /> EH 14-26 d GS <br /> i <br />