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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA n I� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f; <br /> 9 T, 4- <br /> (Complete in Triplicate) <br /> N <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. <br /> .U __.,._-_ �7'/ City ' Lot Size �T f r PM <br /> Joh Address _ / �_ / - y�- <br /> Owner's Name CA10/1/e�� KO/,///,r Address 1�3 f.-. (f�/ __ Phone <br /> Contractor Address - _/J License No._� Phone I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL rrEPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR"❑ OTHER ❑ <br /> DISTANCE TO NEAREST:''SEPTIC_TkNK-""'•""""'"'— "SEWER LINES— °-'° """"'OISPGSAL'FL-D"""°'"'" "PROP"ZINE'""-- <br /> FOUNDATION_ = - ' .AGRICULTURE WELL. OTHER WELL PITS/SUMPS y <br /> INTENDED USE TYPE OF'WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ElOpen Bottom'" ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications' <br /> f7 Public 1 ❑ Other X171 Delta Depth of Grout Seal Type of.Grout 1 <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by _ \` <br /> Repair Work Done' ❑ Type of-Pumps =-- H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 ' <br /> Depth Filler Material (Below 501 . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I i DESTRUCTION XiNo septic system permitted if public sewer is <br /> available within 200 feei.) <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/Mfg Capacity 1No Compartments <br /> PKG. TREATMENT PLT. ❑ le Method of Disposal <br /> Distance to nearest: Well "Foundation Property.Line - <br /> LEACHING LINE; ❑ No. & Length of lines Total length/size j ti <br /> FILTER BED r ❑ Distance to nearest: Well Foundation Property Line ' <br /> - i <br /> SEEPAGE PITS I I Depth Size Number f <br /> SUMPS L1 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 applica t must-call-for-ell-required-inspections.—Complete-drawing-on reverse-side.—�— <br /> y( Signed X Title: � t /� Date; <br /> (1 <br /> FOR DEPARTMENT USE ONLY �l <br /> Application Accepted by Date �J. ,Area <br /> Pit or Grout Inspecti Date Final Inspection by Date <br /> Additional Comments: _ <br /> ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 u <br /> .Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. d <br /> +.EH 13-24(REV.1i1451 13 7X7 <br /> EH 14.28 U ' <br />