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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District, <br /> Job Address � � �� . <br /> p" p�r�_ City Lot Size PM <br /> I <br /> Owner's Name Address .0 1.9f�e per! Phone <br /> Contractor f.. /�r1GG�� Address r D / /�v� /SSP License Ivo.� _Phone <br /> TYPE OF WELL/PUMP: °_ .a —NEW-WELL ❑I.F-t WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP,INSTALLATION ❑` SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK< SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEPA AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial •=❑ Open Bottom ❑ Manteca r/ Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ GraJel Pack ❑ Tracy• Type of Casing Specifications <br /> ❑ Public ❑ Other 5 Delta; � Depth of Grout Seal t Type of Grout <br /> ❑ Irrigation �_,-,...Approx. Depth6i❑ Eastern Surface Seal Installed by I 0JRepair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction El Well Diameter Sealing Material (top 50') # f 6 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INS ALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> avilable within 200 feet.) <br /> Installation will serve: 7 esidence—y— Commercial Other <br /> Number of living units: _/_ Number of bedrooms t <br /> t ; <br /> Character of soil to a depth_of 3 fleet: �/ �DS/ �C4A;% _ _Water table depth <br /> SEPTIC TANK ElType/Mfg`. 1�i4F 1 Capacity 4?et: 'f No. Compartments <br /> 1.PKG. TREATMENT PLT. ❑ t [` ,/" I Method of Disposal I a <br /> Distance to nearest: 1Well Foundation � Pro erty Line <br /> , i• �� S r �' <br /> LEACHING LINE f ❑ No'..& Len th of lines SCS <br /> g � D Total length/size <br /> FILTER BED '"� Distance to nearest: Well f._F r Four ndation_l'�F77 Propetty Line <br /> SEEPAGE PITS ❑ Depth SizeNumber <br /> SUMPS ❑ Distance to nearest: Well roundAtion Property Line <br /> DISPOSAL PONDS (] f u Y F; <br /> 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 /> j The applicant must call for a!I quir inspections.-Complete drawing on reverse side. ; <br />` Signed l Title: A—" rl Date: �y���J4 <br /> r I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area 13 <br /> Pit or Grout Inspection by } Date' "" Final Inspection by RDate-k—) <br /> F <br /> Additional Comments: <br /> ❑ Stk 466-6781 ?❑ Lodi 369-3621 anteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental eal Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> T INFO AMOUNT DUE--' —AMOUNT REMITTED"" CASH RECEIVED EY DATE" ' " PERMl7"lV(7" <br /> + EH13-24{pE{J,'7/s 51 <br /> EH 1426 `' Y5011 �.5 O <br />