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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 11,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 /> Job Address c City Lot Size PM <br /> Owner's Name loci A .A,A.�_ Address Phone <br /> Contractor Address 312TV License No. 1_3A`l1,�� Phone—1/7 <br /> TYPE OF WELL/PUMP: „r„,._NEW,WELLzCI,w,,,_ �._ WELL.REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES k DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL r OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE QF WELL PROBLEM,AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottorrf ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Y ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing .e _ Specifications <br /> F! Public_ _ ❑ Other___ ❑ Delta Depth of Grout Seal ` Type of Grout _ <br /> i I 1 Irrigation - —.Approx. Depth l I Eastern Surface Seal'lns�tal d by <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done_ r <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> v <br /> Depth m Filler Material f Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRlADOITION I I DESTRUCTION (No septic system permitted if public sewer is —` <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other t <br /> Number of living units: Number of bedroommi r ___,- r <br /> Character of soil to a depth of 3 feet: _. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg " Capacity' _- No. Compartments <br /> ` PkG. TREATMENT PLT. ❑ .. e � �w Method of Disposal <br /> Distance to nearest: ,Well Foundation - Property Line <br /> LEACHING LINE Cl No. & Length of lines'"' ,Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 1 <br /> SEEPAGE PITS I l Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 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 i <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." <br /> The applicant m call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: _ 7,— Z V <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 2 2 3—5 Area ,l t <br /> Pit or Grout Inspection by � Date Final spection b Date <br /> Additional Comments: ; <br /> ❑ Stk 466-6791 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 <br /> f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> FEE AMOUNT DUECK <br /> INFO +7 AMOUNT REMITTED DASH RECEIVED By DATE PERMIT'NO. <br /> ♦ EH13-241pFV,;rinsl102*41 , <br /> EH 14-2e - (/ <br />