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x <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 Joaq bCounty 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 $ City Lot Size PM <br /> Owner's Name '`` Phone �•� <br /> ContrlScie� C� `��1(� O qdd 1 I ff � Q C.`� f C\TL Lense Z- Phoney <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ElDESTRUCTION Dol <br /> ..I <br /> PUMP INSTALLAT�IIO'N, SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:-SEPTIC TANK �y._�.— SEWER LINES JU p DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial en Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 2145roomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Ste' resh� Specifications <br /> l7 Public w .3 1-3 Other Ll Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _-Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump k!:p H.P. 2-.- State Work Done_ <br /> Well Destruction -❑ Well Diameter Sealing Material (top 501 <br /> f Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: 'NEW INSTALLATION 1.1 REPAIR/ADDITION E I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) ; <br /> h <br /> Instaliation will serve:^,Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK­ ' ❑"Type/Mfg' Capacity No, Compartments <br /> PKG. TREATMENT PLT, ❑ _ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line i <br /> i T � <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line <br /> 61 <br /> SEEPAGE PITS F l Depth Size Number <br /> SUMPS _ ❑;,Distance totiearest: Well Foundation Property Line <br /> iF- <br /> DISPOSAL PONDS 0 <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 taws of'Califoinia."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 /> i I <br /> The applicant must call for all'Irequired inspections. Complete drawing on reverse side. <br /> Signed X Title,4C� Date. <br /> R. FOR.DEPARTMENT USE ONLY pp�� <br /> Application Accepted byDate �� Area V <br /> Pit or Grout Inspection b r"//7A res p e �i,�{7 �- Final Inspection by Date/ 4 <br /> Additional Comments: <br /> ❑ Silk 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 /> yl-r �Y a j J S'+k}ter/ �- e h� -e�p[,c,y.t e J �v, L,/e f( d r;FEE <br /> Ilk ai <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. JN/ <br /> + EH 13-241REv.1i851 ._�7 / 97 1 <br /> EH 1426 <br />