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APPLICATION,FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i (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 /> rA <br /> Job Address {1L` !"1 ! 'v tJ& d�.c.( City Lot Size PM <br /> Owner's Name Address 16 ! a WPhone <br /> Contract Address ��, SL",l�. 742/ �License Na• o�6c7a� Phone 60-5lo� <br /> r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r+ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> y <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i <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 ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION iEr REPAfR/ADDITION ❑ DESTRUCTION ❑ (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: _L_ Number of bedrooms <br /> Character of soil.to a depth of 3 feet: __ -/I- . <br /> ­­ ­­I a - ... Water table depth <br /> SEPTIC TANK R Type/Mfgj Capacity ffaa d No. Compartments <br /> f.. <br /> PKG. TREATMENT PLT. ❑ -�,� Method of Disposal <br /> C�- <br /> Distance to nearest: Well�� Foundation 16_.. Property Line S f <br /> LEACHING-LINE 93' No. & Length of lines 7 _ Total length/size /20 ,1��__,� <br /> FILTER BED ` ❑ Distance to nearest: Well_ Foundation 10 Property Line .� f <br /> f-- <br /> SEEPAGE PITS Depth 'Q-SE $ize. Number 3 <br /> SUMPS ❑ Distance to nearest: Y Well 16d Foundation 10e Property-Line S� <br /> DISPOSAL-PONDS' -❑_. _ <br /> I hereby certify.that I have prepared this application and that the work will be done in accordance with San Joaquin county ordlnances;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: "I certify that ih-the performance of the-work,for which this.-permiVis 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 subcontracting signature <br /> j certifiestherfollowing: "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 ust call f all r wired inspections. Complete drawing on rev)eAside. <br /> Signed Title: �,/ ` ► Date <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> } <br /> Application Accepted by Date Area <br /> -, x / 4 <br /> Pit or Grout Inspection by Date Final Inspection byLI� Date�i ;Rig 1 <br /> j.Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. Box 2009, Stk., CA 95201 111 <br /> R INFO AMOUNT DUE ACK <br /> MOUNfT REMITTED CASH RECEIVED BY DATE (jP/E_RMIT"NO. <br /> + EH 13-24(REV.1: 8G) I - V -00.. l��l. ' �Y I,L+v�`—^"•' dW~�J p� <br /> EH 5428 <br />