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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> x" <br /> 41. <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permi$/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 /> - <br /> Job Address z + City + J Lot Size �S ¢ ply <br /> Owner's Name Oe i [�L-4 Address 44 AZ Phone <br /> Contractor ke 0- Address S h'tTX License No4 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ _ SYSTEM REPAIR EJ OTHER Ll �.} <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 1;'. PROP. LINE 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I' <br /> (D Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private--- ❑'Gravel Pack ❑ Tracy Type of.Casing Specifications <br /> ❑ Public V1 -+- —F Othet ❑ Delta Depth of Grout Seal Type <br /> ype of Grout <br /> ❑ Irrigation a; _Appro Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work D6ne ❑ Type of Pump H.P. L State Work Done_ <br /> Well Destruction ❑ Well Diameter {- Sealing Material 6613'50'). <br /> p a Depth Filler Material-(Below 50'1 -4`a. <br /> ,TYPE-OF SEPTIC WORK:/NEW INSTALLATIO -REPAIR/ADDITION ID DESTRUCTION 0 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve:. ;Residence_ Commercial_ Other {•-.,x <br /> Number of living units: I Number of bedrooms _ 3 <br /> Character of soil to of depth of 3 feet: Water table depth <br /> K } <br /> SEPTIC TANLVType/Mfg.- VC Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ :•+-*"� <br /> - Method of Dis o I <br /> iDistance to nearest: Well DO l Foundation Property Line <br /> LEACHING LINE r �No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well���-LFoundationCy _ Property Line _ <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well&��F..ndati.n Property Line <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 ordinances, 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 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 /> The applican n1u t call for all required inspect, ns. Complete drawing on reverse side. <br /> Signed X Title: <br /> Date: Z <br /> FOR DEPARTMENT USE: ONLY L <br /> Application Accepted by Date v Area <br /> r <br /> Pi or Grouta Inspection by-1-0401 ate Final Inspection by;,f—It ate <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369 §2,1 '❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant-r Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r. <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH13.24(REV.iin51 <br /> EH 1426 G1 O�o—�l - <br />