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t <br /> f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> i <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> - (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. This application is <br /> made in compliance with San Joaquin Counry Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. I <br /> ryS!O S,( .c. <br />{ Job Address ! t� 4T75C '0n <br /> j City Lot Size_ PM <br /> Owner's Name L wtL Address 3 r 1 <br /> Phone <br /> I Contractor Address [7 h �7 <br /> License No.J773 aS Phone '3 �— <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT D DESTRUCTION ❑ <br /> PUMP INSTALLATIONNe SYSTEM REPAIR D OTHER Ll <br /> DISTANCE TO NEAREST; SEPTIC TANK 'LO SEWER LINES 't DISPOSAL FLD. PROP. LINE 60 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation 4F P —` Dia. of Well Casing <br /> )'Domestic/Private Gravel Pack ❑ Tracy Type of Casing �VG Specifications <br /> F1 Public FI Other Cl Delta Depth of Grout Seal _ t� <br /> p S ._ Type of Grout CC/?� <br /> I i Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by C_j;kt, A <br /> Repair Work Done ❑ Type of Pump' } J�� <br /> P -�'_-SC/� H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter+ Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted il,public,sewer is" <br /> available within 200 feet.)" <br /> Installation will serve: Residence Commercial ercial_ Other <br /> Number of living units: Number of bedrooms 1 <br /> Character of soil to a depth of 3 feet: I Water table depth � ! <br /> SEPTIC TANK ❑ Type/Mfg 1 Capacity--. -- Coln'-Compa—Reefs t' f, 1 <br /> PKG. TREATMENT PLT: ❑ 1-1 r <br /> Method of Disposal t <br /> Distance to.nearest Well Foundation f Property Line <br /> LEACHING LINE D No. & Length of lines (Total length/size <br /> FILTER BED 0 Distance to nearest Well Foundation I 1 <br /> Property Line <br /> i s r i li <br /> SEEPAGE PITS I I Depth I f Size Number <br /> SUMPS L1 Distance tornearesi: Well _ Foundation { Property Line <br /> DISPOSAL PONDS 1-1 � I � <br /> herebycertify that I have " <br /> Y prepared this application and-that-the work will'4e done in accordance with San Joaquin county ordinances, state laws, and ` <br /> rules and regulations of the San Joaquin Local Health Di%trict. F <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 1 <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." r ' <br /> The applicant must <br /> cl for all required inspections. Complete drawing on reverse side. 't <br /> r . ! <br /> Signed X Title:4ACd µData., <br /> FOR DEPARTMENT USE ONLY r I <br /> Application Accepted by Q� / M j <br /> Date Area <br /> Pit or Grout inspection by' Date Final Inspection by Date <br /> Additional Comments: 42/l ,/c, c <br /> F] Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 63546985 <br /> Applicant- Return all copies`to:Environmental Health Permit/Services 1601 E. Hazelton Ave.,_.P.O-Box-21109-Stk7CA'T5201_� f <br /> FEE <br /> INFOjgjDUE AMOUNT R-EEMIITTTED GASH RECEIVED 6Y PATE PERMIT'NO. <br /> r.EH 14.24 1REV. /x 51 EH 14-2a <br />