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APPLICATION FOR PERMIT <br /> i <br /> SAN JOAQUIN'LOCACH€ALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES,1 YEAR FROM DATE ISSLIED'f f" - 1--' 'y <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. w '' <br /> A�,, iM1 <br /> Job Address , � �r;Y4?�L{+ °if City = Lot Size �' PM <br /> c <br /> Owner's Name n�j, Address " hone1�g <br /> Contractor Address/!7 License No. � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ # <br /> v <br /> PUMP INSTALLATION ❑ _I. 41SYSTEM REPAIR'E] <br /> OTHER.J �. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS'_ <br /> INTENDED USE TYPE 0'TWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom' ❑ Manteca Dia. of Well Excavation pia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack 3! ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ii ❑ Delta Depth of Grout Seal Type of Grout <br /> LJ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by, •:' <br /> Repair Work Done t Type of Piimp„Ar1 t� H.P,f Stdte'Work Done P <br /> Well Destruction ❑ Well Diameter 1 Sealing Material (top 501 L Y`,af <br /> Depth Filler Material (Below 501' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑'(No septic system permitted if public sewer is 1/g <br /> I; 0 available within 200 feet.) f <br /> Installation will serve: Residence ai— #Commercial_ Other <br /> !Number of living units: Number of bedrooms { LA <br /> f <br /> Character of soil to a depth_ofF3 feet: " �""""�-Water Table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity -,-No. Compartments <br /> PKG. TREATMENT PLT. ❑ };y f x ' `,�sL �'c ` "Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ -No. &4Length'of lines Total length/size <br /> FILTER BED -1 Distance to nearest: Well Foundation Property Line <br /> r SEEPAGE PITS ❑ Depth.:? %_ Size _ _ Number <br /> - <br /> SUMPS s ❑ Dista ce to nearest Well Foundation -�— Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have preparedthis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, arfd <br /> rules and regulations of the San Joaquin Uocal'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."Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that j6 the 6erformance 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 ust�call fo I required <br /> inspections. Complete drawing on rrse ide. <br /> Signed k ; / . ., - Title: lDate": /�V� <br /> 'FOR DEPARTMENT USE ONLY <br /> Application Accepted by �'f Dat:1�5�� rea V <br /> Pit or Grout Inspection y DateFinal Inspection b Dated <br /> i <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 07 Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE .PERMIT'NO. <br /> INFO <br /> + EH1324IREV.7/est <br /> EH 1426 b S <br />