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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone 120111466-6781 <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.4 " <br /> Job Address <br /> i City Lot Size ��'7� e PM <br /> Owner's Name �CL ' ' £� Address 9'1 <br /> '�'�•�Phorte �3J�� �� <br /> Contractor Pet Address�� F Pied J� d6J=�6i6 <br /> TYPE OF WELL/PUMP: FT <br /> License No. Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUC fl N ❑7' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0 HER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK fit. <br /> SEWER LINES DISPOSAL FLD: PROP. LINE (� <br /> FOUNDATION AGRICULTURE WELL Z� r--,OTH€R WELL \ <br /> 1 PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTROCTION SPECIFICATIONS (� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of.Well cavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑._Tracy Tj " ��, Dia. of Well Casing 1 <br /> ❑ Public Type of caasjng =�_ Specifications <br /> } <br /> ❑ Other ❑ Delta DI I of Gfout Seal <br /> ❑ Irrigation # j d Type of Grout <br /> ---Approx. Depth ❑ Eastern Sprface Seat Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction ❑ Well Diameter I State Work Done <br /> Sealing Ma aerial iR 50`) `r <br /> Depth Fitler Material {gej' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LiREPAIR/ADDITION DE TRU <br /> CTION ❑ lNo septic systems permitted if public sewer is <br /> P / available within feet.) <br /> Installation will serve: Residence l S Commerciai Other I <br /> Number of living units:� Number of bedrooms , �✓� <br /> Character of soil to a depth of 3 feet: 's'� � rj r <br /> � ^ �•"r Water table depth <br /> SEPTIC TANK ❑ Type/Mfg i, f.� , v <br /> Cepa ity� a No. Compartments \ <br /> PKG. TREATMENT PLT. ❑ �y-/� , I;- <br /> � �5 �,- Method of disposal <br /> Distance to nearest: WallF <br /> Fou datio ---- Property-Line­-i <br /> LEACHING LINE No. & Length of lines Q kcr <br /> �''� Total length/size <br /> FILTER BED <br /> ❑ Distance to.nearest: Well <br /> I I D Foundfati�n Property Line <br /> SEEPAGE PITS <br /> ❑ �]epth Size Number <br /> SUMPS ' <br /> Distance to,nearest: Well�_ Foundation � <br /> DISPOSAL PONDSti E1 `J Property Line- •- <br /> I hereby certify that I lhAve prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws <br /> rules and regulations of the San Joaquin Local Health District. , and <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 inch manner as to become subject to workman's compensation <br /> certifies the following: hisPlaws ss California."Contractor's hiring or sub contracting signature <br /> g:"I certify that in the performance of the work for which this permit is issued, I shah employ persons subject to workman's compensa- <br /> tion laws of California.- <br /> The applicant must for all required in tions. Complete drawing on reverse side. <br /> Signed / Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Datel �Z6 � <br /> Area <br /> Pit or Grout Inspection by Ah Date Final Ins , <br /> pection by Date <br /> Additional Comments: <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. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE t AMOUNT REMITTED CK <br /> �tCASH ` RECEIVEi3 BYE �OATE `PERMIT'NO. <br /> 6 <br /> + EH 13-24(REV.ties) <br /> EH 1428 �o <br />