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APPLICATION FOR PERMIT - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEI_TON AVE.,-STOCKTON, CA <br /> I <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 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. 5+9e65 X6_ 40--W-,34 <br /> Job Address City Lot Size ��� PM <br /> i <br /> Owner's Name W D.o, 4Address k. .4G Phone- a L. - <br /> ­ 21c.ontractor's Name L� License No. _ 75J!��� _ Phone 11,2 3 <br /> TYPE OF WELL/:PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. t 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public f ❑ Other ❑ Delta Depth of,Grout Seal Type of Grout <br /> I---_ <br /> E] Irrigation ; ---Approx. Depth ❑ Eastern .Surface Seal Iinstalled by <br /> Repair Work Done ❑ Type of Pump H.P. I State Work Done ' <br /> Well Destruction; ❑ Well Diameter j Sealing Material_ftop_50'f r� <br /> Depth Filler Material IBelow 501 19� <br /> F TYPE OF SEPTI WORK: NEW INSTALLATION REPAIR/ADDItION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is U <br /> _.available withii6 200 feetf -- <br /> �. <br /> ` "'""Installation`w�ll`se'nre:"Res'idence L Commercial� Other <br /> i <br /> Number of living units: ` Number of bedrooms <br /> Character of soil to a depth of 3 feet: A Aq 8� Water table depth <br /> SEPTIC TANK C9 Type/MfgCapacity f LNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Cr,M0L.O ,foundation Property Line , <br /> i <br /> LEACHING LINE No. & Length of lines 3" /1JTl f ' rfl� <br /> 9 1, Total length/size <br /> FILTER BED ❑ Distance to nearest: ~ 4eLll Foundation 0 Property Line <br /> f I <br /> SEEPAGE PITS ❑ Depth Size I Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done inlaccordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. I a <br /> Home owner ori 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." Contractor's 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 /> The applicant must call for all re ired inspections. Complete drawing on reverse side. <br /> .Signed X lP• � ��,�-� Title: <br /> Date: <br /> i FORD PA'RTMENT USE ONLY 1 <br /> s <br /> Application Accepted by M-1 Date 0`- / Area <br /> r <br /> Pit or Grout Inspection by Date Final Inspection by r Date <br /> 4 Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH—'-RECEIVED-BY-1 --DATE--', -.PERMIT NO. <br /> + EH 13-241REV.10183) <br /> kk EH W26 <br /> l' _ <br />