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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, .CA <br /> Telephone 4209) 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 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 /> 4: It .s1 <br /> Job Address r l 'So t +�1C 1� V - <br /> CityK Lot Size � Ply) <br /> Owner's Name <br /> Address Phone <br /> I Contractor '� �( RO4(9 ., .- <br /> �� � Address License Na.� Phone_ <br />' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 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 C] Gravel Pack Ll Tracy Type of Casing _ Specifications <br /> M Public ❑ Other El Delta Depth of Grout Se a-, Type of Grout ! <br /> ! I Irrigation —_Approx. Depth l 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 50') <br /> Depth Filler Material (Below 50') <br /> -.TYPE OF SEPTIC-WORK: NEW INSTALLATION 11 REPAIR/ADDITION)(I DESTRUCTION [ 1 (No septic system permitted if public sewer is l� <br /> available within 200 feet.) <br /> Installation will°serve: Residence_ Commercial_ Other <br /> Number of living,un4s: Number of bedrooms . s <br /> Character of soil toga depth,of 3 feet: <br /> SEPTIC TANK; � �T-te/Mf rw"'""'"."-"'' " <br /> Water-table depth <br /> ._ g v Capacity y ; No. Compartments <br /> PKG. TREATMENT PLT. ❑ P Method of Disposal <br /> ^.� <br /> Distance "to nearest:w w.Well •Foundation Property Line <br /> .v LEACHING LINE• 1 .N.-o, & Length of lines <br /> footTotal length/size <br /> FILTER BED ❑ Distance to,nearest: ,.,WeII t _.12 0 Foundation -15r, <br /> oert p y Line <br /> SEEPAGE PITS nQ -I 1 Depth Size "'" Y <br /> ­YIVu--mbar � <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL.PONDSX. <br /> - ❑ <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 <br /> rules and regulations of the San Joaquin Local Health District. laws, and <br /> r. r » -- <br /> Home owner or licensed agent's signature certifies the- <br /> following: "I certify that irtihe performance of the work for which this <br /> employ an permit is issued, I shall not <br /> A Y y person in such manner.as-to;become subject fo workman's compensation-laws-of.California. Contractor's hiring or sub-contracting signature <br /> certifies ttia fallowing: "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 app) must call fo quired inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: <br /> Date: _ Q <br /> FO DEPARTMENT USE p1ULY <br /> Application Accepted by <br /> Date Area 7 <br /> Pit or Grout Inspection by Date Final In bye` <br /> Oat <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant - Return all copies to: Environs ental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Silk., CA 95201 <br /> FEE 1 <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> CASW RECEIVED BY DATE PERMIT•NO. <br /> +.EH 13-24 IREV.1/b 5} <br /> EH 14-26 —4 ^y <br /> �! <br /> r <br />