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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES V 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. IW2 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Q �{ <br /> Job Address 4 L �� f� City Lot Size- _✓ 49.AgA PM <br /> Owner's Name titA11 Address 1701 S. &bAft, . Phone <br /> Contractor T 1� �� Address License No. Phone 6LS <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 17 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUND AGRICULTU LL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL OBLE A CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom a a Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'l Public "� ❑ Other ❑ Delta De of Grout Seal Type of Grout—_­ <br /> I <br /> rout _. <br /> I } Irrigation pprox. Depth i^I Eastern Surface Se stalled by <br /> Repair Work Done Type of Pump H.P. to Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 50') _ V� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I } REPAIR/ADDITION I 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. ❑ 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 I I 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." 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 m st all f all a tre n ta9plsto drawing on reverse side. <br /> Signed Title: IQ At€"e— � Data. 7/3 t <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 7 Z7 <br /> Additional Comments: ['� <br /> ❑ Stk 466-6781 ❑ 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 95MI <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED A5H RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13-24 IREV.F/H 51 3S O� tJ�/ rr'-` ! I_, <br /> EH 14-26 f N <br />