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APPLICATION FOR PERMIT <br /> SAN JOAQUINIOCAL HEALTH DISTRICT <br /> 1601,E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209? 466-6781 <br /> PERMIT EXPIRES 1`YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> A_ <br /> Application is hereby made to the San Joaquin Local Health District-fora permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance N6:49 for sewage or No. 1852 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. +; I <br /> � /��`t iii .� s • rC� t` - <br /> Jab Address .�I /'�� a 1 /�(lf �`LJT�.. _ Cit ZLot Size PM <br /> f/ <br /> Owner's Nam I/A/ ;I /Lt/L j -'Address - Phone <br /> —A 4 4 <br /> Contractor Address 1�:C✓�-Qi/Li`6 License nNo." Phone` —Y <br /> TYPE OF WELL/PUMP: NEW WELL `❑ - WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 <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 "PROBLEMAREA CONSTRUCTION SPECIFICATIONS' <br /> LJIndustrial 1-1Open Bottom,.--`� ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel'Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---4ppmx. De" ❑ 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 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> U� (� <br /> Installation will serve: Residence_ Commercial_ Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: �`�`+�' <br /> p Water.table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t <br /> PKG. TREATMENT PLT. ❑ Method of Disposdl <br /> a <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> c' t <br /> SUMPS © Distance to nearest: Well Foundation Property Line i <br /> DISPOSAL PONDS ❑ t L <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 l;shall <br /> , an <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 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 sgature a <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 Cal' ia." <br /> The applicant ust call for al re uired ins c tins. C mplete drawing on r rse side. # <br /> Signed / Title: / _. Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by i Date rS <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by 7:�J �1 6 <br /> Additional Comments: / <br /> ❑ Stk 466-6781 ❑ Lodi 359-3821 ❑ Manteca 823-7104 C ❑ Tracy 835-6385 0- ; <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> .. F <br /> FEE <br /> 'INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. r <br /> + EH13-24 fFEV.1/e5; . -IDS <br /> EH 14-23 <br /> i <br />