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APPLICATION FOR PERMIT <br /> SAN JOAQUIN'LOCAL'IHEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM"DATE ISSUED r <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address Z e ," ('% z - City` Lot Size PM <br /> Owner's Name AddrePhone <br /> ContractCb Address Q- '861 �7167 r ` License No. 2 �60 Phone36Fi.SICK <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 ❑ ripen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications In1 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout W <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by S 4 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') <br /> Depth Filler Material (Below,501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR DD1TI0 DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) ` <br /> Installation will serve: Residence_/ Commercial_ Other �{'� y��,r-�E r � �� •-- --f <br /> Number of living uni ts: ' Numbero&bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth' <br /> SEPTIC TANK. ❑ Type/Mfg i Capacity No. Con�pattments_-,�, ._. �_- <br /> PKG. TREATMENT PLT. ❑ Method;of disposal <br /> ' S �Distance to nearest: Well Foundation Property,Line,- <br /> LEACHING <br /> ine,LEACHING LINE ! ❑ No.>A Length of lines j Total length/ze.f <br /> FILTER BED ❑ Distance to nearest: Well .^LFoundation +. Property Line r ✓ <br /> SEEPAGE PITS = Dept !Size �o Number . v `. <br /> SUMPS ❑ Distance to nearest: ;Well_00 Foundation 16 Property Line 5 - <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that i have prepared this application and-that-the-work-will-be-done'in accordancef with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. f- w <br /> Home owner or licensed-agent's-signaturecenifie-s the following: "I certify that in the performance of the work for which thispermitis issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Gontraator'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 Cal-ifornia," <br /> The applica must call r a"(eq ed inspections. Complete drawing on reer'e,si <br /> Signed Title: V' Dat f t L <br /> I <br /> —i FOR DEPAR ENT USE ONLY <br /> Application Accepted by22 4 Date '°' Area <br /> Pit or Grout Inspection by ate Final Inspection by� zn::fDate <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE* AMOUNT.REMITTED CASH <br /> RECEIVED BY DATE PERMIT`NO." <br /> + EH 13-241REV.I/s5) - C 6 +� - <br /> EH 14 26 �] <br /> I <br />