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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 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 /> Oil , { <br /> Job Address Q ` "! 0 kNZ � <br /> City Lot Size PM ttnn � <br /> Owner's NamePhone q. if lAddress Rx -Q71r? � �� -(FZ f~ <br /> Contra ctord9ierl'��,��yy�" Dals'po'! Address ! i�+ <br /> License No. Phone b <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER � r i! ��«'I <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 i <br /> ❑ Domestic/Private C] Gravel Pack' ❑ Tracy Type of Casing Specifications ,r^v <br /> F1 Public C1 Other 1-1 Delta Depth of Grout Seal Type of Grout _ t/1 <br /> I I Irrigation —.Approx, Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Pone_ <br /> O 6 <br /> Well Destruction ❑ Well Diameter ealin Mater( I[tSp-5@! <br /> lii 4 <br /> S{1I P �+ �1 Depth r Filler Material (Below 50') <br /> SGC vAQrJ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted it public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Numberofbedrooms <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. © Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I g � <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED L1 Distance to;nearest: Well FoundationProperty Line <br /> .' <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 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: "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." I <br /> The applicant must call for all required ns i ctio s. Complete drawing o reverse side. <br /> Signed XY ✓` Title: 4 <br /> 6� <br /> Date: <br /> D ENT USE ONLY <br /> Cl <br /> Application Accepted by Dateeaj <br /> Pit or Grout Inspection by Date Final Inspection b � 'Date 2-T� � <br /> Additional Comments: r S lit' (/jl s1 t / <br /> C7 Stk 466-8781 El Lodi 369-362f ❑ Manteca 823-719 ❑ Tracy 56385 ©s <br /> Applicant• Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE I <br /> INFO JAMOUNT DUE S/AJM(OUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> r.EH t3-24{REY.i/H51 5✓ 66 'J+. 6U '-G -761 Z / - (� ��j-1 76 <br /> EH 1428 ✓ s`- !/ � <br />