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APPLICATION FOR PERMIT <br /> SAN JOAO,UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES YEAR FROM DATE ISSUED <br /> IComplete 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 Ryles and Regulations of the San Joaquin <br /> Local Health District, ,av <br /> Job Address ���' c.L '' City <br /> PM <br /> t7' T'Lot'Site 3/a ' X 70� , <br /> Owner's Name 1 ddress r. �� :�?•� 4C4hone -7-a-7- 33Jl <br /> Contractor "����d�G "� 'i/��'W Addressl 2 R /�. License Na."E�10� 1 Phone s l�'al J <br /> TYPE OF WELL/PUMP: i NEW WELL 19L WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PR P. LINE GQ <br /> FOU AGRICULTURE WELL OTHER WELL PIT SUMPS �Es� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r t <br /> ❑ Industrial POpen Bottom ❑ Manteca Dia. of Well Excavat' n Dia. of Well Casing <br /> Domestic/Private 11 Gravel Pack ED Tracy Type of Casing77 /a2 f4, Specifications <br /> Q Public ❑ Other ❑ Delta Depth of Grout Seal 5-O ► <br /> P _ Type of Grout <br /> ❑ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth) Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 'il. available within 200 feet.) <br /> Installation will serve: Residence_ Commercial. Other <br /> Number of living units: 11 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 /> Distance to nearest: W Foundation Property Line T' <br /> LEACHING LINE ❑ No! & Length of lines �f 7 Total I �rty <br /> FILTER BED ❑ Distance to nearest: Well 0 oundation Proe fff <br /> SEEPAGE PITS ❑ Depth -Size"" Number <br /> SUMPS ❑ Distance nearest: We J` Foundation ` Property Line_&'>S <br /> DISPOSAL PONDS ❑ I� <br /> I hereby certify that I have prepared this applicstion and that the work will be done in accordance th 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 followings"I certify that in the performance of the work for which this permit is issued, I shall not ,' i <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 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." IM <br /> The applicant mu call for all regluired insMc• Complete drawing on reverse r4de. <br /> Signed ��. Title: ,tel Date: 7" Z-1— <br /> OR DEPARTMENT USE ONLY " <br /> r <br /> Application Accepted by Date Area <br /> AA;", <br /> Pit or Grout Inspection by Date inal Inspection by Date e i <br /> Additional Comments: <br /> Q Stk 466-6781 Lodi 369-3621 Q Manteca 823-7104 ❑ Tracy 835-6385 ' '" <br /> Applicant- Return all c ". <br /> pP pies to: Environmental Health permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT'DUE AMOUNT REMITTED CKCASH RECEIVED BY , DATE PERMIT NO.. <br /> 400 <br /> EH 4-26 <br /> + EH 13-24(REV.i/s 5) `� i <br /> 1 `-' lit - / L-f � +��0q <br />