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APPLICATION FOR PERMIT <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE; TON AVE., STOCKTON, CA �� �� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) n „ ,t <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. fJ <br /> Job Address �1s.2 1r %. ,�-Grp-*�Cav�- City LotSize arm PM <br /> Owner's Name CAP-M--Al AIA 4.4—4�,_ Address Phone <br /> Contractor /=Lrs yd g. AladO D Address Aed r Al, ,e►I/E License No. G Phone <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 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C� <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ln1 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump t �'. H.P. State Work Done <br /> Well Destruction ❑ Well Diameter * ,Sealing Material (top 50') <br /> Depth Fifler.Material-(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDIT ON_❑_DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) O <br /> Installation will serve: Residence-`:_� Commercial_ Other # <br /> Number of living units:_/_ Number of bedrooms f <br /> Character of soil to a depth of 3 feat: s Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments <br /> PKG. TREATMENT PLT. ❑ - I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line i <br /> LEACHING LINE ❑ No. & Length of lines r Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> ( <br /> SEEPAGE PITS ❑ Depth I Size Number <br /> SUMPS ❑ Distance to nearest: Well'"""""—""""--Foundation""' 1 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 applicant must call for all required inspections. Cp1plete drawing on reverse side., <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by C ®� Date �'r 1 7 Area a <br /> Pit or Grout Inspection by Date Fi all Inspection by + Dat <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3921 ❑ Manteca 823-7104, ❑ Tracy 8356385 <br /> t 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 C A RECEIVED BY DATE PERMIT*NO. <br /> ' INFO r <br /> +EH 5&241REV.7/e57 �V V lots ' j�1 + �Zjq <br /> I` EH 14-25 { r V q l <br />