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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I 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 P C/ vim' City K Lot Size PM <br /> �//7/Oh OfC <br /> Owner's Name �I / Address 2�7� 1Y' Comkyar'q14 Alv Phoneyzs'- d,_4� <br /> Iowa <br /> Contractor okk J LA ddress - bee t. • License No. �1e4 Phofle <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �yfLa;c <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 it <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatiog Dia. of Well Casing L <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ilUG Specifications 1 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seala Type of Grout 1&177 ' <br /> ❑ Irrigation 4'QApprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Al <br /> _.. Sealing Material atop <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 II <br /> Character of soil to a depth of 3 feet: -7 1Watdr table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments <br /> PKG. TREATMENT PLT. ❑ ' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ` <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I 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."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." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> 9 Title: Date: <br /> 61 i <br /> FOR DE TMENT USE ONLY <br /> 00 <br /> Application Accepted by Date _ rea_. <br /> Pit or Grout inspec' ate Final Inspection by Date <br /> r i <br /> Additional Comment <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ nteca 823-7104 ❑ Tracy ars ` ®�y,,��� `�' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`'N0. <br /> +EH 13-24(REV.)/95] <br /> EH 14-26 <br /> i <br />