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APPLICATION FOR PERMIT <br /> .R <br /> SAN JOAO,UIN LOCAL HEALTH DISTRICT . <br /> 1601,E. HAZEL i ON AVE., STOCKTON, CA . <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application,is he 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 � �' ST_ City S "1 ;Lot Size /"X, 1 x0' PM <br /> Owner's Name —F_>1 C1e- STRAW 64)� Address 2 5� Pq c.,,F1 LAve Phone <br /> Contractor <br /> Wde'D Address. License No.6�y76 Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> IN USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial El Open Bottom ❑ Specifications Manteca Dia. of Well Excavation Dia. f Well Casing <br /> � fications <br /> Ll Domestic/Private E1 Gravel Pack_ L1 Tracy Type of Casing <br /> ❑ Public ❑ Other ❑ Delta Depth.of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction L1Weil Diameter Sealing Material )top 501 <br /> Depth Filler Material {Below 501 <br /> � TYPE OF SEPTIC WORK: NEW INSTALLATION.C] REPAIR/ADDITION Ll DESTRUCTION (No septic system permitted if public sewer is <br /> t available within 200 feet.) <br /> Installation will serve: Residence Commercial='. Other <br /> I Number of living units: Number of bedrooms 1 <br /> Character of soil to a depth of 3 feet: t - � _ Water table depth 1I <br /> ,f achy No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg p <br /> I <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest. V11e1 Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines - Total length/size <br /> FILTER BED A EDDistance to nearest: well Foundation Property Line <br /> I SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to�nearest: r Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> 4 rules and regulations of the San Joaquin Local Health District. <br /> l 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." �« <br /> I The applicant must call for all required inspe ns. Complete drawing on reverse side. <br /> s <br /> Signed }r T Title: <br /> &Ztl& Date: G -`d 9 7 <br /> s <br /> FOR DEPARTMENT USE ONLY 4--b <br /> Date 6-- �� Area D / <br /> Application Accepted by r <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 1 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> + EH 1324IREV.t/asIINFO <br /> EH 14-26 <br />