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APPLICATION:FOR PERMIT E <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ....r. . . r re, -:f <br /> PERMIT EXPIRES`1 YEAR FROM DATE ISSUED <br /> ssr i7.(Complete in,Tripiicate) <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 ! �� 1 �� �1. � { - <br /> Vs' �0�_ Ci �s2S X 1 tU D PM <br /> Lot:Siz <br /> `�,Bx �3 j Li <br /> Owner's Name Address ""�� � , <br /> Phone -� <br /> Contractor plljc� Address r <br /> Licensee No_ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C ., <br /> R 1 PUMP-INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LJV( �� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE \J�r <br /> f i FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy i Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Deltaf Depth of Grout Seal Type of Grout <br /> EJIrrigation ___gpprdx. Depth ❑ Eastern r Surface Seal Installed by ` <br /> Repair Work Done ❑ Type of Pump H.P. State W rk Done_ l <br /> Well Destruction Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUC N ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms �. I <br /> Character of soil to a depth of 3.feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mf '' <br /> g Capacity— No.No. Compartments <br /> PKG. TREATMENT PLT. El 13.1 1 i 1 _ Method of Disposal <br /> Distance to nearest: Well' � t .Foundation Property Line <br /> T� <br /> LEACHING LINE LlNo. & Length of lines { a'c � _ Total length/size <br /> FILTER BED ❑ Distance to nearest: Welli pFoundation Property Line <br /> 7 <br /> SEEPAGE PITS ❑ Depth size Number <br /> SUMPS ❑ Distance to nearest:r .r"Well - Foundation Property Line <br /> DISPOSAL PONDS ❑ I , <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. f G <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."Contractors 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." f _ <br /> The applicant mu II for all re qu' i pections. Complete drawing onjjAwerse,side. <br /> Signed . 11 <br /> d 1 Title Dater <br /> FOR DEPARTMENT USE ONL Y4' / } <br /> Application Accepted by Date r Area <br /> Pit or Grout Inspection byDate_LWMFinal Inspection Date <br /> Additional Comments: j <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 4❑ 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 CK RECEIVED BY DATE PERMIT"NO. <br /> + EH13-24(REV,ri,v5) <br /> EH 14-28 5 • y /3 , <br />