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t-. APPLICATION FOR PERMIT • <br /> } SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �( 1601 E. HAZE.—J 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 Rules and Regulations of the San Joaquin <br /> Local Health District. ®®�{{���//���,, <br /> Job Address - � KJ �A--�/' Cit%/_1M05VL Lot Size PM <br /> Owner's Name f ��� � 1� Address "- L0 la�_ p5w 0'10- Phone z e7 <br /> Contractorf ur XkL'�'�{I'AddressM 57 <� -"e No Phone <br /> TYPE OF WELL/PUMP: NEW WELL' WELL REPLACEMENT X DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑TI <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD �ROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT2NS .. <br /> ❑ industrial ❑ Open Bottom anteca Dia, of Well Excavation J Dia.of Well Casing <br /> e,5-1mestic/Private 10, ravel Pack ❑ Tracy Type of Casing PVC-- &0 /�� Specifications <br /> ❑ Public �❑,Ort�h"er ❑ Delta Depth of Grout Seal � %-,� Type of Grout <br /> ❑ Irrigation #.d.L.LApprox. 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 /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <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. ❑ e Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of Ilnes Total length/size <br /> FILTER BED ❑ Distance to rie8rest: Well Foundation Property Line 40 <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 t I all r ired inspections. Complete drawing one side. <br /> Signed j Title , 4 ^ � Date: r- <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Q�'jL Date Area <br /> Pit or rout nspection by Da Final Inspection by Date <br /> Additional Comments: l7 l U lC�-fly <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Wnteca 823-7104 O Tracy s <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED CCAK# RECEIVED BY DATE PERMIT`NO. <br /> + EH 13-24(REV.i/8 5) ° C <br /> EH W28 5,/gar— J ZA <br />