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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 1209] 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I� (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. I- _ I <br /> Job Address _6fJ7�3 pad" City Lot Size PM <br /> Owner's NameAddress Phone <br /> Contractor Address BA4Z �OyLicense No. S�396y _Phone '_-JS'J <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPL-JACEMEN7 ❑ DESTRUCTION El <br /> PUMP INSTALLATION SYSTEM REPAIR'ix 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 x 'PROBLEP7 AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom <br /> p ,r'`u�� C3 Manteca 4 Dia. of Well Excavation Dia. of Well Casing W <br /> k]omestic/Private ❑ Gravel Pack ❑ Tracy z Type of Casing Specifications W <br /> I'1 Public F) Other i l Delta Depth of Grout Seal Type of Grout _ W <br /> I I Irrigation _11Approx. Depth i I Eastern l Surface Seal Installed by _ <br /> Repair Work Done f[ Typeh of Pump./-mow' H,P.. State Work Done <br /> ..i <br /> Well Destruction ❑ Well Diameter Sealing,Material (top 501 <br /> Depths Filler Material {Below 501 /1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION,[ I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) r^ <br /> Installation will serve:; Residence Commercial Other <br /> Number of living units:- Number of bedrooms <br /> Character of soil to a depth f 3 feet: - Water table depth <br /> SEPTIC TANK ❑ Type/Mfg '` Capacity No. Compartments O <br /> PKG. TREATMENT PLT. ❑ 11 ,� Method of Disposal <br /> Distance to nearest: Wel! , Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines 'w. Total length/size <br /> FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line <br /> 1M k <br /> SEEPAGE PITS i I Depth Size Number <br /> 'h <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Ll <br /> I hereby certify that I have prepared this'application and that the work will be donein accordance-with-San.Joaquin county ordinances, state laws, and <br /> rules and regulations of the San'Joaquin'L'ocal-Health Di§trict. <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(tiring or sub-contracting signature <br /> certifies the following: 1 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." If ' -1 <br /> The applicant I! for allrequired inspections. Complete drawing on reverse side. <br /> Signed X a �,F Title:4 �=Dd— __ _- " Date: �(� <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by I� Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 456-6781 ❑ Lodi t 369-3621 0 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 /> FEEI�. <br /> INFO ALUNTE AMOUNT REMITTED `` �CA3H RECEIVED BY DATE PERMITNO. <br /> 1::: <br /> + EH 13-24(REV.ti ae) t."L �ft�j11331 <br /> EH 14-25 tttPPP 1 ! ✓ <br />