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APPLICATION FOR PERMIT W(v <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 /> � <br /> Job Address Z 0 City Lot Size33O�X 66oi PM <br /> Owner's Name � Address Phone <br /> Contractor 1 ' j Address License No.,r��d�l 1 Phone 4 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C] ,_ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 1/ 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 /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SpecificatioHns <br /> e <br /> F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. *j State Wbrk Done— <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 f t <br /> „a `p'r ek:'r/ •�' ` <br /> Depth Filler Material (Below 501 ('v` <br /> TYPE OF SEPTIC WORK: ,EW INSTALLATION 1.1 REPAIR/ADDITION 1'i DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> r x kM available within 200 feet.) <br /> Installation will serve: Residence.�1�__ Commercial— Other <br /> r Number of living units: Number of bedrooms f-4) <br /> Character of soil to a depth of 3 feet19 Water table depth <br /> SEPTIC TANK Type/Mfg 42ft"'.-TE Capacit FCPO No. Compartments <br /> PKG. TREATMENT PLT. ❑ _ _ Methodof Di s 0 <br /> o neares <br /> Distance'tt:� Foundation Well � Fdation_ � 'Property Line <br /> 1 <br /> LEACHING LINE No. & Length of lines A K/, l Total length/size 7 <br /> FILTER BED ❑ Distance to nearest: Well Foundation ef� Property Line <br /> e f. <br /> SEEPAGE PITS l 1 Size '� umber <br /> SUMPS �tan, nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i <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. s I <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 shalt 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 /> x certifies the following: "I certify that in the performance of the work for which this'parmit is issued, I shall employ.persons subject to workman's compensa- <br /> tion laws of California." 4 <br /> The applicant must call for all required inspections. Complete drawing on reverse side. -• �� <br /> Signed X_ J .�C/`at.r_l.�' � f <br /> 1/�C Title: _ C,� �`s "tDate: <br /> k r � <br /> FOR DEPARTMENT USE ONLY <br /> ' t <br /> Applicatff Accepted by ' Date �Z ^— Area <br /> T Pit 0141 ar tion Date a-�­?"iL(4Final lnspaction by <br /> Additional Comments: <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, AMOUNT REEmiTTED CK RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24IREV.'r/H5) 0-0 <br /> 1,7 <br /> EH 14-26 GC> cJ <br />