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APPLICATION FOR PERMIT F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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 /> s. L E. ,. � 3 City�� Lot SizeCi ts��PM <br /> Job Address. <br /> Owner's Name.f ��°33� Address �� ��� Phone <br /> Contractor LEE, 'R �-- Address License No. 3�gar Phone _ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> -- y —PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl <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 /> Q Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other . 1-1Delta Depth of-Grout Seal Type of Grout <br /> A ElIrrigation ___Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done a Type of Pump H.P. State Work Done <br /> Well Destruction E] Well Diameter - Sealing atenal stop�a0'1 4 <br /> Depth Filler Material-1 Below 'l <br /> TYPE OF SEPTIC WORK: NEW-INSTALLATION ❑ REPAIR/ADDITION ❑ (No sepeiwsithin ystem feet.)miitted if public sewer is <br /> 77 <br /> Installation will serve: Residence`commercial Other <br /> Number of living units: � �Number of bedrooms <br /> E <br /> k Character of soil to a depth of 3 feet: _ . E'sT I Water table depth <br /> Ii SEPTIC TANK ❑ Type/Mfg Capcity No. Compartments <br /> PKG. TREATMENT <br /> Method of Disposal <br /> PLT. D { <br /> Distance to nearest: Well Foundation Property Line <br /> ��:&Length of lines Total length/size. <br /> LEACHINGILINE <br /> i FILTER BED ❑ Distance to nearest: Wel Foundation Property Line <br /> I ! <br /> i <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS Ll 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 /> rule`s and regulations of the San Joaquin Local Health District. <br /> llowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the fo <br /> j employ any person in such manner as to become subject to workman's compensation laws of California." Contrac or's hiring or sub-contracting signature <br /> If certifies the following: 1 certify that in the performance of the work forwhich this permit is issued,1 shall employ p rsons subject to workman's compensa- <br /> tion laws of`fornia." <br /> Th lican m tall fora req din cti S. m Drawing on reverse si e.Title1� <br /> t : Date: a <br /> Signed � <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byr � <br /> Date Area C1 Ut <br /> Pit or Grout Inspection by �., Date—oma_ Final Inspection by Q Date - 3^n�P <br /> Additional Comments: <br /> Stk 466-6781 ❑ Lodi 369-3821 ❑ Manteca 823-7104 ❑ Tracy 835 — <br /> A plicant.-'Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stk., CA 95201 <br /> a <br /> T FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT N0. <br /> INFO ��'/ <br /> + EH 13-24(REV,1/e51 7 -7p � Vi ��^S�d <br /> EH 14-26 <br />