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't <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 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 /> Job Address c=4t� y <br /> d CityF_5- r��cry -Lot Size PM <br /> Owner's Name U &igale it /4-! r Address 1C Phone <br /> Contractor's Name Iy d R1 164C 14 110 e License No. A-1 a 70,?'7 C Phone /-/A74 S? e <br /> TYPE OF WELL/PUMP: I[ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ \� <br /> DISTANCE TO NEAREST: SEPTIC!.TANK /J� SEWER LINES DISPOSAL FLD. PROP. LINE v <br /> IM FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I�1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial L lOpen'Bottom L1 Manteca Dia. of Well Excavation <br /> 'k Dia. of Well Casing <br /> O`Domestic/P�ivate ❑ Gravel Pack ,r ❑ Tracy Type of Casing Specifications <br /> 1i k. <br /> ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 01 Irrigation _„___Aprox. Depth '❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of'Pump ""`^�*�- ,H.P. i State Work Done y Well Destruction ❑ Well Diameter Sealing Material (top 50'i <br /> Depth ,' Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION ❑ DESTRUCTION C1,(No septic system permitted if public sewer is <br /> 16! ­­11�• — . � ya�lable within 200 feet.) <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 ' ^s <br /> SEPTIC TANK � Type'/Mfg �a �- Capacity /1000 _ Nv. Compartments ! + <br /> PKG. TREATMENT PLT. ❑ ` Method of Disposal <br /> If Distance to nearest: Well <br /> ! �M _j� l _ Foundation Property Line <br /> LEACHING LINE �[R. -.No. & Length of lines Total length/size <br /> FILTER BED ElDistance to nearest: WellfJ I <br /> ;�6_ Foundation Property Line a <br /> � <br /> SEEPAGE PITS (y Depth w�J�r Size .310.. Number o� <br /> "SUMPS Dist nce to nearest Well d0 f Foundation Property Line <br /> DISPOSAL PONDS ❑ � }' <br /> t <br /> 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 whichithis 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 p y persons subject to workman's compensa <br /> tion laws of California." , <br /> The applica ust call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: �— �_ �1 7 <br /> +� / Date: _l —dL <br /> I� OR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> I , <br /> Pit�or Grout Inspection by I� Date Final Inspection by � ate <br /> Additional Comments: <br /> .;❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201FEE CK <br /> i <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE' PERMIT"NO. <br /> + +REV.10/831 <br /> EH W26 <br /> I a�: <br />