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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone !2091 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 fdr 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. �! r iyPd At d1._ City Lot Size PM <br /> Owner's Nameag <br /> I Address p, <br /> ,. <br /> f� Phone <br /> ContractAddressV.0 1J �ftG! License No.-_7 YZZa <br /> �r <br /> Phone d 4�fO <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION F 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 Excavationi <br /> Dia. of Weil Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ TracyType of Casing Specifications <br /> FI Public Cl Other n Delta _Depih.of Grout Seal <br /> Type of Grout <br /> I i Irrigation <br /> --Approx. Depth I I Eastern Surface Seal Installed by . <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material flop 501 <br /> Depth - er Material Belo 50'1 1 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAI /ADDITION l DESTRUCTION I I INo septic system permitted ifI's �+J K <br /> public sewer <br /> Z/ available within 200 feet.I <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: � Number• edro ms <br /> Character of soil toa_depth of_3-feet:_— P <br /> +.� Water table depth Q <br /> SEPTIC TANK ❑ Type/Mfg `Capacii <br /> Y ' No. Compartments r <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> '�- Distance to nearest: Well Foundation Property Line <br /> t LEACHING LINE ❑ No. & Length of lines A <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well FoundationProperty Line <br /> SEEPAGE PITS 1`r Depth Size x� t[7" - ^ �-- Number r <br /> SUMPS Li Distance to nearest: Well Q F r <br /> Foundation Property Property Line e5 <br /> x DISPOSAL PONDS ❑ ,-f- t <br /> I hereby certify that I have pr'epated this application and-.that the work will be done in accordance with San Joaquin county ordinances, state laws, ander <br /> rules and regulations of the Sa`n Joaquin Cocas HealthFDistiict. <br /> Home owner or..licensed;agerit'saignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any persbn,in such manner as'to become subject to workman s compensation laws of California." Contractors hiring or sub-contracting signature <br /> certtionsfies the laws offCalifornia."llow : "I certify that in the performance of the vo r6or which thilpermit is issued, I shall employ persons subject to workman's compensa- <br /> The applicant m t calf for req ed inspections. Complete drawing on reverse idf) <br /> Signed X <br /> Title: a <br /> bate: <br /> E <br /> FOR DPARTMENT USE ONLY <br /> � 2 i,,� <br /> Application Accepted by 2 <br /> � ! gyp► Area <br /> /11y Grout inspection by 4 pato_37_ � Final Inspection by iii/// * Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201 <br /> QL <br /> FEECK <br /> INFO' AMOUNT DUE AMOUNT REMITTED <br /> CASH RECEIVED 6Y OATE PERMIT'NO. " <br /> + EH 1324 1 REV. <br /> EH 14.26 <br />