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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 12091 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. Ar <br /> �• <br /> Job Address _-, City `* Lot Size Lo W6 PCO PM <br /> { <br /> ,a,� Owner's Xalma Address 1-t-` tt: Ph0ne4;V- 93 <br /> Contra Address License°No. L � phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ^` <br /> Wi t---- -----� - -_ ---PUMP-INSTALLATION-;e ---• ISYSTEM-REPA1Rw❑----— - '-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 p' <br /> *Romestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications s �+ <br /> ZI <br /> ublic ❑ Other 13 Delta Depth of Grout Seal Type of Grout <br /> rigation —Approx. D ❑ Eastern Surf Seal Installed by <br /> e <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> P TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) ✓E C <br /> Installation will serve: Residence— Commercial_ Other tom. 't <br /> Number of living units: Number of bedrooms i 3 <br /> Character of soil to a depth of 3 feet: Water table depth Q <br /> I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line ' ! <br /> DISPOSAL PONDS ❑ ---- _ 'S <br /> I 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 /> F rules and regulations of the San Joaquin Local Health District. ` -}�r `'Ff '� t• ` <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 /> r: <br /> employ any person in such manner as to become subject to_workman's compensation laws of California:­—Contractor's hiring or contracting signature <br /> certifies the fo ing: "I certify that in the orman ec of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of ali rnia." # ,r] <br /> The applic t m st call for required ins ti I e drawing�side:i AA 1 <br /> Signed Title: -� - Date: S �' <br /> ' FOR DEPARTMENT USE ONLY a s <br /> Application Accepted byDate Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 1_/70 <br /> ❑ Stk 466-6781 ❑ Lod' 369-3621 ❑ Manteca 820104 v q Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1641 E. Hazelton Ave!, P.O. Box 2009, Stk.,, CA 95201 <br /> J <br /> FEE AMOUNT DUE AMOUNT REMITTED CKOCASH <br /> RECEIVED BY DATE PERMIT NO. <br /> INFO - <br /> + EH 13-241REV.t/s5) � <br /> EH 14-28 <br /> t � <br />