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K APPLICATION FOR PERMIT <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 /> —!p <br /> pplicaion 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 Regul ions of the San Joaquin <br /> Local Health District.« Q�� ,� ��� /►, �� ' Q z <br /> Job Address "' -G+2 oltt".Ri Jj G City �% Lot Size PM <br /> Owner's Name N-f7addres Q 5z o 4'Ct� phone <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 1J, WELL REPLACEMENT ❑ DESTRUCTION—P <br /> s <br /> `+ PUMP INSTALLATION ❑ � �' SYSTEM REPAIR ❑ OTHER ❑ _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> t FOUNDATION r AGRICULTURE WELL OTHER-WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA`f CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca:- ;Dia. of Well Excavation Dia. of Well Casing �Y ) <br /> ❑ Domestic/Private ❑ Gravel Pack I] TracyType of Casing Specifications- n <br /> ❑ Public ❑ Other L3-Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _--Approx. Depth ❑ Eastern •F � Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. — ` ate-Work Done • _ <br /> Well Destruction Well Diameter /0 // Sealing Material {top <br /> 1 <br /> Depth -JD Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑. REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) C <br /> Installation will serve: Residence_ Commercial— Other i <br /> Number of living units: Number of bedrooms low A <br /> Character of soil to a depth of 3 feet: _ '` - ""' l Water table depth -' 1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity i No. Compartments <br /> PKG..TREATMENT PLT. ❑ �— <br /> y ---- Method of Disposal -� <br /> Distance to nearest: .R Well a Foundation Property Line <br /> r <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 ❑ <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. <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."Contractor's hiring or sub-contracting signature <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 California." <br /> The appli n)nust call for al �irelctions. Complete drawing o arse side. i <br /> Signed t Title <br /> Date: <br /> 1. FOR DEPAR ENT USE ONLY <br /> Application Accepted by G✓ Date %r�^ '7 Area <br /> Pit or Grout Inspection by Date Final Inspection by (kitfi7 Date ' i <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all cgpjes�r,vironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r1� jrA 3/1'LA <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. I <br /> + EH 13-24(REV.1 <br /> EH 1426 0/93) 10-0 <br /> 1 <br />