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L APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> j PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' <br /> (Complete in Triplicate) . 77 <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 Ryles and Regulations of the San Joaquin <br /> -Local Health District: ' {z: <br /> Job Address 77 at City Lot Size RM <br /> Owner's NameAddress' ^ Phone <br /> V <br /> Contractor ZIZ( /a/ Address Y,c�)t •� 14-1 License No - Phon �'� v\ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - <br /> PUMP INSTALLATION SYSTEM REPAIR.Ll 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 <br /> ❑ Industrial ❑ Open Bottom , , ❑ Manteca + Dia, of Well Excavation Dia. of Well Casing <br /> cam-. <br /> Of-9omestic/Private ❑ Gravel Pack ❑'Tracy r# i,_v. Type of Casing Specifications <br /> _ _LOl Public ❑ Other--= ❑-Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �__Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump _ H.P. / State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') - - <br /> 2epth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> t available within 200 feet.) <br /> Installation will serve: Rdsidence_ 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.- *'_- a No. Compartments <br /> PKG. TREATMENT PLT. ❑ ---_ �---� <br /> '-`� '•'-`t - --­--, --Method-of Disposal"- <br /> 'Distance td nearest: Well Foundation Property Line <br /> ' f <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth f $ Size Number <br /> SUMPS ❑ Distance to nearest: Well FoundationProperty Line <br /> DISPOSAL PONDS LI #" r ,' •� ,, ,- -. ." <br /> I hereby certify that l 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." Contractors 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 applican I far all re 'red in ti s. Complete drawing on reverse side. <br /> Signed XR - Title:_ * Dater �1" <br /> k. I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date g" _ Area <br /> C)9 —-- <br /> Pit or Grout Inspection by ..t Date_ Final Inspection by1 Date 7, <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 j <br /> Applicant- Return all copies to: Environmental-Health Permit/Services'1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> j <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT`NO. <br /> + EH 13-241fiEV.t/651 <br /> EH 1426 Olp t <br />