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APPLICATION FOR PERMIT <br /> [ �•t' el ��e -,:4- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA I <br /> Telephone f209) 466-6781 <br /> r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v <br /> in ate)Tr <br /> ic <br /> )_V7 —O 20 -Dl <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. 18662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. {Y, j L f�,,�f'w ��rf�r L y" C Le,• O�rlrG`t 4 tr. <br /> Job Address <br /> City Lot Size PM <br /> - <br /> e <br /> Owner's Name Address Phone <br /> Contractor�'�S Address 7Z cSKhS License No. E,300� Phone 7 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ ," DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ "4= SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEARES SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL V PITS/SUMPS r_4y <br /> INTENDED USE TYE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . _w if7 <br /> Ll Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public '❑ Other C) Delta Depth of Grout Seal Type of Grout <br /> i <br /> It,Y`rrigation7,�-.Approx. Dept I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P <br /> State Work Done O <br /> Well Destruction ❑ Well Diameter t S aling Material Itap 50') <br /> Depth Filler Material {Below 50') (, i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I -.REPAIR/ADDITION ! I DESTRUCTION 1 i INo septic system permitted if public sewer is f <br /> f available within 200 feet.) I` <br /> Installation will serve: Residence Commercial' Other W <br /> Number of living units: Number of bedroomsI _ <br /> Character of soil to a depth of 3 feet: <br /> "' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ '""�'�.'• <br /> 4 Distance to nearest:' Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines ' Total length/size .� I <br /> FILTER BED ❑ Distance to:nearest: Well 41 Foundation Property Line j <br /> C i <br /> SEEPAGE PITS i I Depth SizeNumber rn <br /> SUMPS ❑ Distance to nearest: Well Foundation 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 /> 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." i <br /> The applicant ust c I for all requir d inspe tions. Complete drawing on reverse side <br /> t � p <br /> Signed X # Title: Date: 2 <br /> �a <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> �n» Z _ C <br /> Application Accepted by ='Date Area <br /> Pit or Grout Inspection Date Final:thspection by D e <br /> r Additional Comments: -4 ge 4' & + Z <br /> ❑ Stk 466-6781 ❑ 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 /> r <br /> i INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> �.EH13-24(REV.1/H5) <br /> EH 14-2e f <br />