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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 Q <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 /> �J P ��'q <br /> Job Address City ee�� Lot Size� `�> -C15 � "'^\�® PM <br /> - - <br /> Owner's Namep9Address 0 *6-_30'9 Phone <br /> Contractor It -� rA Address License No. -/Z3 R(919Phone_ !9 <br /> TYPE OF WELL)PUMP: W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTf <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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public C1 Other L 1 Delta Depth of Grout Seal Type of Grout <br /> I t Irrigation ­Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done_ Q <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLAT N Cl REPAIR/ADDITION f I DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Q <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms_tel— d <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg =_,�Q.�� Capacity._ `O <br /> �pl; ___ No. Compartments <br /> PKG. TREATMENT PLY. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of-Vi - Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS Property Line <br /> CI <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 Di%trict. <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: '9 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 m t 11 for required inspections. Complete drawing on reverse side. <br /> Signed X Title: <br /> Date: <br /> C�AFOR DEPARTMENT USE ONLYApplication Accepted by t! Date_L4 Area <br /> f <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <br /> Additional Comments: 4 c $ <br /> ❑ Stk 466-6781 LI Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <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 CK <br /> INFO C SH RECEIVED 6Y DATE PERMIT'NO. <br /> + EH 1 -241REv.1iR51 =0�- <br /> EH 114-2e `// <br />