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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.. <br /> Job Address QJed City Lot Size PM <br /> Owner's Name ] ( -, Address=', hf:L'P- Ct Phone <br /> Contractor �Lt�47�� Dam 6� 3 l�^,_ r �-� <br /> ( f'�Y Address 1" 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 FI—DIM--t—PROP. LINE "V <br /> FOUNDATION AGRICULTURE WELL OTHER WELLPITS/SUMPS / <br /> INTENDED USE TYPE OF WELL PROBLEM AREA M CONSTRUCTION SPECIFICAT ONL, ci <br /> ❑ ndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` <br /> Domestic/Private Gravel Pack ❑ Tracy �Type of Casing Specifications a <br /> ❑ Public ,�❑,,O,fth�er C3 Delta ` Depth of Grout Seal Type of Grout n � <br /> 171 Irrigation l)J�Approx. Depth ❑ Eastern 16Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P, -State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 C_ <br /> Depth Filler Material (Below 50)',4- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-0—DESTRUCTION ❑INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve Residence_ Commercial_ Other` s -y <br /> Number of living units: Number of bedrooms > <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.,❑ Method of Disposal <br /> ,y <br /> Distance to nearest: Well Foundation Property Line 1 <br /> LEACHING LINE " ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 3 I <br /> . 1 <br /> SEEPAGE PITS ;!D Depth Size Number j <br /> SUMPS ` J❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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." <br /> The applicant I for all requ• d nspections. Complete drawing on re,14se <br /> ,., side. <br /> Signed Title: l-tC®7 Date: <br /> FOR DEPARTMENT USE ONLY { <br /> Application Accepted by Date \tl -\ '� Area <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by Date ` <br /> - r l i <br /> ' Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546395 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT NO. <br /> .EH 13-24(REV.rias) 7 <br /> �. .':H 14-28 l'O <br /> �7 , 1 <br />