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APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE,, STOCKTON, CA 0 <br /> 'Telephone (209) 456-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> -(Complete in Triplicate) <br /> Application <br /> Application is hepeby 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.—­­ <br /> Ir <br /> istrict.— ' <br /> � <br /> Job Address �oZQB. O �`Ay� °' r•. F - a. rS <br /> City. TD <br /> of Size v PM <br /> ro _ <br /> 4 Owner's Name Address Phone- Y - <br /> Contractor ~' <br /> � Address QDOAlVLD License No. fob'&!bpane <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ _ DISPOSAL.FLD.. PROP. LINE <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE Ol WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open 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'Se61"` <br /> ❑ Irrigation _Approx. Depth ElEastern Surface Seal Installed by—k. f Type of Grout <br /> Repair Work Done ❑ Type of Pump - � H-P 1 <br /> State Work Done <br /> Well Destruction ❑ Well Diameter "'Sealing Material (top 50') i <br /> Depth ? 1Filler Material {Below 50 J-1- t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑` REPAIR/ADDITION ❑ DESTRUCTION: (No septic system permitted if public sewer is <br /> 'Navailable within 200 feet.) <br /> Installation will serve: Residence _ Commercial "Other # <br /> Number of living units: Number of bedrooms': i <br /> .- Character of soil to a depth of 3 fest: Water table depth <br /> SEPTIC TANK El Type/Mfg <br /> _'. Cap?�y No. Compartments <br /> PKG, TREATMENT PLT. ❑ I -_ Method of Disposal <br /> Distance t nearest: �= Well . Foundation <br /> Property Line ; <br /> f e <br /> y <br /> LEACHING LINE ❑" No. & Length of lines ^*� " "`' Total length/size <br /> I <br /> FILTER BED ❑ Distance to nearest. i"Well - # — <br /> Foundation `Property Line' j <br /> SEEPAGE PITS ❑ " Depth "... .- Size « ��, __.• _ .- i <br /> Number <br /> SUMPS ❑ Distance to_nearest:......�WeEI— ----.�:w�'Foundation=�-�-="•�-pFoperty <br /> DISPOSAL PONDS ❑ <br /> 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:""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." <br /> The applicanust call for all require d inspections. Complete drawing on reverse idg. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byAA <br /> L f�'L� 0 <br /> Date Area <br /> Pit or Grout Inspection by �7/ Date I Final Inspection byDate <br /> Additional Comments: Er <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH13-24(FIEV. H 51 <br /> EH 1428 J r i .]�: �O - /Z I <br /> _ 1 <br />