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i APPEICATION'FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209} 466.6781 <br /> PERMIT EXPIRES i 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 <br /> Job Address ! e r City Lot Size <br /> PM <br /> Owner's Name d-22� �XL(�C/LJ°�1 _ Address <br /> ' Phone <br /> ` Contractaf, t.l.G.Q Det �7 r _ <br /> Address I- C!. License NoZ2 , a 6 Phone (c6 c� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LiNE <br /> "FOUNDATION AGRICULTURE WELL OTHER WELL ' PiTS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial <br /> ff Open Bottom ❑ Manteca Dia.of Well Excavation r <br /> EJ Domestic/Private ❑ Gravel Pack EJ Tracy Dia. of Well Casing <br /> Type of Casing <br /> Specifications <br /> i ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> type of Grout <br /> ❑ Irrigation <br /> --Approx. Depth ❑ Eastern Surface Seat Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth ler Material (below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAI ADDITION DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> Installation willserve: Residence Commercial_ Other available within 200 feet.) <br /> Number of living units: Number of b Brooms <br /> _ { I <br /> Character of soil to a depth3`of feet`:"' � <br /> Water table depth <br /> SEPTIC TANK LJType/Mfg _ � : f <br /> CapacityIVo..Compartments <br /> PKG. TREATMENT PLT. IJ • .f .� <br /> N r I&Method of Di osat <br /> Distance to nearest: Well Foundation Pt <br /> rope Line _ <br /> LEACHING LINE ig�_No. & Length of lines "' t 1 x a <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well 85- f k r <br /> r Foundations _ pFop�ity Line <br /> SEEPAGE PITS ❑ Depth Size` <br /> -Number.t <br /> SUMPS ❑ Distance to nearest: Well Found ion } .� <br /> DISPOSAL PONDS. ❑ + .1 Property Line <br /> I hereby certify that I have prepared this application and.th'at 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 I <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 Perwrmance of the work for which this permit is issued, I shall employ,persons subject to workman's compensa- <br /> tion laws of California." 9 is <br /> The applicant st call for equ•ed inspections. Complete drawing on reverse ide. <br /> Signed rifle: `i ` <br /> -- '' Date: <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by Dateor <br /> Area a k <br /> Pit or Grout Inspection by <br /> Date Final Inspection by� /i�.� Date �' �6 <br /> Additional Comments: ` <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 ' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT''NO. <br /> + EH 13-24(REV.1/6 5) <br /> EH 1426 � ' <br />