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APPLICATION FOWPERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT- <br /> 1601 <br /> ISTRICT1601 E. HAZE T ON AVE.or.STOCKTON, CA <br /> Fi Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) w a r <br /> Application is hereby made to the San Jdaquin 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 i <br /> Local Health District. V <br /> C { I <br /> Job Address City Lot Size PM <br /> Owner's Name r be VG. `�C3. �f� Address �0. 1:l'��jD Phone <br /> Contractor G L f7 ,i-12L� Address �— LJ Phone <br /> License Na. P— <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Jffi 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 v <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications a <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> F ❑ Irrigation ---Approx. Depth Eastern S ace Seal Installed by <br /> Repair Work Done K1 Type of Pump H.P. -- State Work Done /r <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> f Depth Filler Material-(Below.50D? . <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: 1Nater table depth <br /> SEPTIC TANK ❑ Type/Mf <br /> g Capacity No. Compartments . <br />` PKG. TREATMENT PLT. ❑ R tr17,11 Method of Disposal <br /> Distance to nearest: Well'r 'rFoundatian Property Line <br /> LEACHING LINE ❑ No- & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest:. Well Foundation Property P rtY Li ne , <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well foundation -Property Line ; <br /> DISPOSAL PONDS ❑ 1 <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 appRe 7ntst call for all re ired ins tions. mplete drawing on re a side. <br /> E Signed X Title: Date: —A-e-2 � <br /> FOR'DEPARtMENT-USE ONLY` :4 <br /> Application Accepted by Date 1 Area O <br /> Pit or Grout Inspecti y Date Final Inspection by DateY ! U a <br /> Additional Comments: r <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 95201 <br /> FEE <br /> INFO AMOUNT DUE -F AMOUNT REMITTED CASH RECEIVED BY I DATE PERMIT•NO. <br /> + EH124{REV.i i e sl <br /> EH 14,28 <br />