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Ems=- APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �r (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 [15` S- BUD V _ City 117 dO /Lot Size �I S PM <br /> ry-, / . <br /> Owner's Name _J k5T//�_ "7�ddress Phone <br /> ContractorIff'ot, AddressO,,I / 1 License No. `7 Phone 6 0163 <br /> TYPE OF P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP I SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ELL PITS/SUMPS <br /> f INTENDED USE TYPE OF WELL PROBLEMiAREA CONSTRUCTION SPECIFICATIONS <br /> []',Industrial ❑ Open Bottom ❑ Manteca ' Dia.,of Well Excavation Dia. o asing <br /> ❑$Domestic/Private ❑ Gravel Pack ❑ Tracy 'Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I <br /> ❑;Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done_ ✓ <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 n <br /> s Vr <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIWADDITION fl DESTRUC I I o septic system permitted if public sewer is <br /> ailable within 200 feet.) Lp <br /> Installation will serve Residence_ Commercial_ Other <br /> Number of living unit's: Number of bedrooms F <br /> Character.of soil to a depth of 3 feet: l Water table depth <br /> SEPTIC TANK / ❑ Type/Mfg, Ca.pacity - .No. Compartments <br /> PKG. TREATMENT PLT. ❑ ' t Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> l <br /> LEACHING LINE ❑ No. & Length of lines i Total length/size <br /> FILTER BED ❑ Distance to nearest: Well I Foundation Property Line <br /> i I <br /> SEEPAGE PITS ❑ Depth, - — Size Number <br /> SUMPS . ❑ Distance to nearest: Well Foundation 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 applicantca or it d i pectio Cam a dr ing on MA# <br /> ideSigned X Title: LLId�L Date: / <br /> - R DEPA� <br /> ENT USE ONLY <br /> Application Accepted by Date ��' _ Area�5! <br /> -Z 7Pit or Grout Inspection by Date Final Inspection by Date _ <br /> I ' <br /> 37 / oLl3 � <br /> Additional Comments: <br /> O'Stk 466-6781 Lodi 369-5621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i - <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT•NO. <br /> 1 INFO <br /> + EM14283-2 <br /> EH 16IREV.i/m51 <br />