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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> v <br /> Telephone (209) 466-6781 <br /> 1 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 /> 14 A <br /> Job Address / P r City Lot Size (7 = .A^-, PM <br /> Owner's !Name �ddyres2 � Phone <br /> _ - :-q�. t�� aswr.c' i--•-�- r• � .. — .. . :.� 5... M -. . sew;.a' - -4.�.. ,....— .-x.- .t-.- .. .... , <br /> Contractor "` .��._ Address 7 License No. Phone <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 r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/P.rivate "¢�' _❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public 5 ': / ' ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation r _..Apprax, Depth-t.[ I Eastern Surface Seal Installed by G <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done _ <br /> Well Destruction "'-D'--Well Diameter Sealing Material (top 50') <br /> "> Depth Filler Material (below 50 <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is 1 <br /> available within 200 feet.) <br /> Instaliation'will serve: 'Residence-V Commercial_ Other <br /> Number of living units: ..._._._._ .Number of bedro W S_� f <br /> Character of soil to a depth of.3 feet: Water table depth <br /> SEPTIC TANK I�Type/Mfg Capacity_ , J QQ Not Compartments <br /> PKG. TREATMENT PLT. ❑ / k ;� Method of Disposal N r <br /> Distance to nearest: Well FoA]ation ,P.roperty.Line <br /> LEACHING LINE a No. & Length of lines Total length/size` <br /> FILTER BED ❑ Distance to nearest: Well Foundation '30 " Property Line. , 571 <br /> SEEPAGE PITS I I Depth r Size Number , <br /> SUMPS ❑ Distance to nearest: Well Foundation _ Pro y Line 741— <br /> DISPOSAL PONDS ❑ J r`i�^,-. `4 <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 /> Home owner or licensed agen't'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 applican ust call for all required inspections. Complete drawing on reverse side, s <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 17 Area• ... <br /> �P t�eSr Grout Ins�ection by Date � Final inspection by1 Date' <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 - <br /> Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,.CA 95201FEE . <br /> A INFO /AjMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> ♦.EH 13-24 tREV,I/x 51 /D.6 b ' 2 .a0 - 'r�,3 <br /> EH t4-26 ff <br />