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APPLICATION FORS 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 FRIIOM DATE ISSUED <br /> (Complete in Tripllicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to Construct and/or install the workherein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Jab Address z City &aj Lot Size PM <br /> Owner's Name; �Q/L (2c . Address /Z Z+/ 1*/A) .,r��� r PFi,e <br /> Contractor f L�J I fJ 1 N& 4Al9S IN Address&A K I�1 i ,�[.$�l,'y�CAL,icense No. Phon6 <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Xi MdNihl.W JL4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I DISPOSAL FLD. PROP. LINE S0 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom 0 Manteca Dia. of Well IExcavation—7 Dia. of Well Casing <br /> 1�Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing Sc, VC_ Specifications <br /> ❑ PublicOther .J ❑ Delta Depth of Grout Seal / Type of GroutC-A,7 t <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump , H.P. State W r Done <br /> Well Destruction ❑ Well Diameter Z- Sealing Material (top 510') <br /> Depth Filler Material (Below 501) ASIEL �1' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/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: Number of bedrooms m <br /> Character of soil to a depth of 3 feet: __- —Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capalcity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line r <br /> L <br /> c <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundatiln Property Line I <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 taws, 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."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 applic t st call for all required ' spec'ons. Complete draw; on reverse side, p <br /> Signed R�. it : '� � Date: <br /> FOR DEPARTMENT U5E ONLY T <br /> Application Accepted by- Date Ci— Area <br /> Pit or Grout Inspection � ,. rata Final Inspection by= Date L, J <br /> Additional Comments: �._ <br /> ❑ Stk 466-6791 �Lodi 369-3621 0 Manteca 923-7104 ❑ Tracy _- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazetton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED ? I RECEIVED BY DATE PERMIT'NO. <br /> INFO t <br /> +EH 13.24fREV.i/B55 � <br /> EH 1425 <br />