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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> Ii (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 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 /> 1 j r Ivf r/ <br /> Job Address 1. .W, V� S� City JW41VLot Size PM <br /> Owner's Name ft� nG fl d kf191G�- Address Phone <br /> r / r <br /> Contractor l� �'�-r� Address 0 License No. � 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 /> f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 6 Public ❑ Other 11 Delta Depth of Grout Seal Type of Grout <br /> — <br /> I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P, Stat Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f.l REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is <br /> ' available within 200 feet.) <br /> is <br /> Installation will serve: Residence_ Commercial_ Other � � x ,,�• <br /> Number of living units: Number of bedrooms y V <br /> Character of soil to a depth of 3 feet: r� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity t No!Compartments <br /> a <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I Distance to nearest: Well "' Foundation k Property Line 6 <br /> i <br /> LEACHING LINE ❑rt No. & Length of lines Total length/size <br /> FILTER BED ❑1 Distance to nearest: Well Foundation ... Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line t <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 Di%trict. —� <br /> Home owner or licensed agent's signature certifies the follo'wind: "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 work n's compansa- <br /> tion laws of California." <br /> The applicant must call for all re it inspections. Complete drawing on reverse side. <br /> Signed "� Title: _ ''f Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by z.2 Date �L Area <br /> s <br /> Pit or Grout Inspection by Date Final Inspection by Dat <br /> Additional Comments: I <br /> 0 Stk 466-6781 D Lodi 369-3621 O Manteca 823-7104 0 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Seniices 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. <br /> ' <br /> *-EH 13-241REV.iiwsl <br /> 3�,t� 35.E 1�3� �'S. 3 -3-8f� S-1'1$p <br /> EH 1.4-26 <br /> A i i <br />