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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELT�ON AVE.,"STOCKTON, CA } <br /> Telephone (209) 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 for a permit to construct and/or install the work herein described. This application iB <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 4 City Lot Siz t ��� PM 1 <br /> Owner's Name V W rWeIM Address L <br /> f A Phone �� i7 0 <br /> F <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑' "`"`"`�— WELL REPLACEMENT, <br /> s ,A DESTRUCTION ❑ S <br /> .ZI,,:iPUMP�INSTALLATIONt❑ SYSTEM REPAIR ❑ s <br /> ` OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE Q <br /> FOUNDATION 4 AGRICULTURE WELL OTHER WELL PITS/SUMPS ti ' <br /> INTENDED USE TYPE`OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial , ❑ Open Bottom ~'❑ Manteca Dia, of Well Excavation Dia. of Well Casing CA <br /> .❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingV. ❑ Public—*,", Specifications } <br /> ti.;.. ❑ Other. ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation "1 4 f ---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 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septiesystem permitted if public sewer is <br /> available within MO feet.f " <br /> installation will serve:'+Reslidence Commercial_ Other <br /> Number of living urijtsi Nu;ber=bf be ooms � <br /> Character of soil to a depth of 3 feet: Water table depth —a <br /> SEPTIC TANK, Type/Mfg's Capacity L--00 N&'CcM—raitments 7- <br /> 4 <br /> PKG. <br /> -- <br /> PKG. TREATMENT PLT: I❑ - f Method of Disposal t <br /> Distance nearest: Well Y17-& Foundation/— Property Line <br /> + i <br /> LEACHING LINE �, No. & Le_ngth of lines _ �d Tota! length/size Q . <br /> i <br /> FILTER BED C7 Distance to nearest: Well Zh D 4` Foundation__/� Property Line - <br /> SEEPAGE PiTS ❑ Depth P"VSize Number <br /> f <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and!tltat the work will be done in accordance with San Joaquin county ordinances, state laws, and I <br /> rules and regulations of the San Joaquin LiAal'Hea14hbistrict. <br /> Home owner or licensed agent's signaturece'ifies 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 beco a suliject to wbrkman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the pe ormance 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 applicant must call for II,req d ins ctions.-Complete drawing on reverse side. <br /> Signed X Title: Date:/1107 ? <br /> OR DEPARTMENT 5E ONLY I <br /> Application Accepted by Date CJ r / —, Area <br /> Pit or Grout Inspection by ,f * _ Date Final Inspection by pate —, _ li <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621. ❑ Manteca 823-7104 ❑ .Trac"y,4.,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 C K a RECEIVED BY DATE PERMIT"NO.' I <br /> + EH 13.24(REV.10183) O <br /> EH 14-26 - 4.J"'' 1. �'t�..i..�'G� <br />