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APPLICATION FOR PERMIT ' <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L5 1601 E. HAZEL—I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 deicribed.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1$62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> r <br /> (.f <br /> Job Address /r / �� .{p/fit, ., City Lot Size S�/ u lU� PM <br /> Owner's Name Address C ! � .t Phone r �� <br /> Contractor A dress-117 /V�fW�i R License No.Ald, <br /> Phone g- <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> .3 FOUNDATION RICULTURE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM R CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mant Dia. of Well Excavation t pia. of Well Casing <br /> * ❑ Domestic/Private ❑ Gravel Pack ❑ cy Type of Casing I Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal I Type of Grout <br /> ❑ Irrigation P --Approx.. pth ❑ Eastern ace Seal Installed by f 4f, <br /> Repair Work Done p � Type of P mp H.P. State Work Done_ 1 <br /> Well'Destruction ❑ Well Diameter Sealing Material (top 50') <br /> t � <br /> I Depth l Filler Material (Below 50') f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPI9/AD ION ❑ DE5 CTIO ❑ (No septic system permitted if public sewer is <br /> R`(/1 available within 200 f t.) <br /> Installation will see: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms r <br /> Character of soil to#a depth of 3 feet: Water table depth <br /> � r <br /> SEPTIC TANK I ❑ Type/Mfg Capacity ! No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nea st: Well dation Property Line <br /> LEACHING LINE ❑ No. & Length of line ` Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth S Number <br /> SUMPS ❑ Distance to nearest: el Foundation Property Line <br /> DISPOSAL PONDS ❑ it <br /> I hereby certify that I.have prepared this application and that thew will be done in accordance with San.Joaquin-county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. I <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.'�'Contract6es4hiring 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 per'soris subject to workman's compensa- <br /> tion laws of California." <br /> The applica must call for II requir d inspections. Complete drawing on reverse side. .r- <br /> r-. 1 P <br /> Signed Title: R Date: 3—2 / <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted`by Data Area Z <br /> Pit or Grout Inspection by ate Final Inspection by !! Date <br /> Additional Comments- rrn L / J <br /> I] Stk 486-67$1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy Q <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BYI -64 <br /> DATE PERMIT'NO. <br /> + EH 13.24(REV.i/s 55 � <br /> EH 14-28 ` <br />