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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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.5A9 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District, <br /> Job Address �� City Lot Size PM <br /> Owner's Name 'l� �, ..-.Z^a di%, e_ Address t ° 6• Phone <br /> ptl Q - 00 gatr�ePI icense No. I33 A 3 Phone 2 -�"�� <br /> Contractor y+ Address_ r, <br /> TYPE OF WELL/.PUMP: N W WELL WELL REPLACEMENT DESTRUCTION-B--" <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES / D 'f' DISPOSAL FLD. PROP, LINE 31 <br /> r ; FOUNDATION AGRICULTURE WELL 1 9O.40THER WELL ft- PITS/SUMPS ~T t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , W <br /> " 4 L►U <br /> ❑ Industrial © Open Bottom ._..❑-Manteca Dia. of WeH-Excavation 1.r ^__ "Dia. of Well Casing 64"' <br /> 1�Domestic/Private Ll'Gravel Pack 11 Tracy Type of Casing—_77N_ ��Specifications <br /> i'7 Public t n Delta Depth of Grout Seal d Type of Grout <br /> I I irrigation a--Approx. Depth ( I 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 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is <br /> ' available within 200 feet.) <br /> Installation will serve: ; Residence_____ Commercial Other r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: - Water table depth <br /> SEPTIC TANK i ❑ Type/Mfg " Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ "�* 1, Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: yWell Foundation Property Line <br /> SEEPAGE PITS { I Depth Size Number <br /> i <br /> SUMPS ❑ Distance to nearest: Well Foundation 'Property Line <br /> DISPOSAL PONDS ❑ e– <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: "1 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 Cillifornia."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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California.", { i <br /> The applicant ust call it required inspections. Complete drawing on rover de. <br /> p 7 <br /> SigneX� y� Title: �� Date: r// "' <br /> FOR DEPAR MENT USE-ONLY µ <br /> Application Accepted by Date Area- <br /> Pit or Grout inspection 6yPate Final Inspection by Date <br /> Additional Comments: 0 f <br /> ❑ Stk 466-6781 ❑'Lodi 369-3621 v ❑ Manteca 4920110.4 fD 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 <br /> INFO AMOUNT DUE }AMOUNT REMITTED K RECEIVED BY DATE 7 PERMIT'NO`. <br /> r EH 13-24[R31 <br /> n <br /> EH 4-26 7-311 i <br /> i <br />