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APPLICATION FOR PERMIT <br /> ,�r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.,;STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR.FROM.DATE ISSUED k <br /> .t" <br /> E2r (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. TMs application is <br /> f made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> f Local Health District. <br /> Job Address cry City _ Lot Size PM <br /> Owner's Name" rj C�a L ' Address G Phone 0 <br /> S \ <br /> Contractor r <br /> �7 Address License No.G�� / y Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ oilWELL REPLACEMENTn DESTRUCTION D �/\1 <br /> PUMP INSTALLATION El � SYSTEM REPAIR L-1OTHERD \ <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWERLINES:1: 1 "— <br /> DISPOSAL FLD. PROP'. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR(`(A', CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial F1 Open Bottom 7 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> "'- ❑ Public El Other ❑'Delta "` DepiK­6f Grout SeaI_ Type of Grout <br /> 11iriigation --Approx. Depth D 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 I —Filler-Material-(Below-501-,.-.-.--.----.-. ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION LJ (No septic system permitted if public sewer is <br /> % /` . - I - available within 200 feet.) I <br /> Installation will serve: Residence_,!__ Commercial— Other <br /> Number of living units: Number of bedrooms_." <br /> Character of soil to a depth of 3 feet: ' - -^*—Water table depth <br /> SEPTIC TANK ❑ Type/Mfgi Capa�ry No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> j <br /> Distance to nearest: Well Foundation•' Property Line t <br /> r LEACHING LINE i �( No. & Length of lines = Total length/size <br /> FILTER BED -❑` Distance to nearest: Well Foundation Property Line <br /> 1t j � � <br /> r SEEPAGE PITS Depth ler Size S 1 Number <br /> SUMPS ❑ [Distance to nearest: Well �. oundatiori 1d Property Line E�16 <br /> �" Tr <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepaied 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 agent's signature District.z ; `, ; <br /> Home owner or licensed a ' certifies the following: ' <br /> 9 g g: "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 cern in the performance of the work for kwhich this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." f f { + <br /> The applica m st c for ail required ' ctions. Completdrawing;o r verse side. <br /> Signed X Title:j Date: r �� <br /> FOR DEPARTMENT USE ONLY <br /> ` � t <br /> Application Accepted by Date Area <br /> f i 1 . <br /> Pit or Grout Inspection b Dater! I� Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 1 ❑ Lodi 369-3621 IO'Msnteca 823-7104 - p 'frracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Pe_r¢}mlit_/Services.1601 E. Hazelton Ave.,-P.O. Box 20o9,_Stk.,,CA_95201..,,,._ <br /> INFQ AMOUNT DUE AMOUNT REMITTED'{, �C SH CK- '.!, {tEIVED BY pATE`� PERMIT NO. <br /> a EH 13-24IREV..i/n5) - - - - }- <br /> EH 14-2s a ca 0wl 37 1 <br />