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3 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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. �y C f <br /> Job Address �✓ 9, 7 ,nY e, Yl�, City r Lot Size C- PM <br /> ) SqA 4y5'12.v <br /> Owner's Name an MQ-' Address 01,613 ���{�,9�F �t►'►� Phone f es Z97 <br /> Contractor Address e 2 A 4,�Af_ V' L �cense No. j7 -Phone 3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN DESTRUCTION ❑ <br /> PUMP INSTALLATION f❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK .. �+ SEWER LINES �� s DISPOSAL FLD. iyCt� PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSI---�� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION_$ <br /> ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casingi�ZE Specifications g�' <br /> i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Irrigation ---Approx. Depth ❑ Eastern Surface Seat Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') IN <br /> Depth Filler Material (Below <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> w available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other F <br /> Number of living units: Number of bedrooms ` <br /> I 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 /> 41 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."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 empioy persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu ca11 for all required ins ns. Complete drawing on reverse side. ti ` <br /> Signed X Title: Date.' <br /> f <br /> FOR DEPARTMENT USE ONLY 7 <br /> Application Accepted by f /}C� Date ).Area <br /> Pit or Grout Inspection by Da a Final Inspection by _ Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑"Lodi 369-3621 ❑ Manteca 823 7104 ❑ acy 835-6386 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY � DATE PERMIT'NO. <br /> + EH 13-24(REV.i/est <br /> EH 1425 <br />