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APPLICATION FOR PERMIT SCANNED <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> 2 Telephone (209) 466-6781 <br /> J 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 Heafth District. f > 1 <br /> Job Address �t:�l�z] rr�,v�.,.•.,. e°/ city f ed6 Lot Size PM <br /> Owner's Name AA XV Ste Address /��'�a��� ��{ Phone <br /> Contractor Address if t+License No. ZAef j-y Phone 7&3 <br /> TYPE OF WELL/PUMP: NEW WELL fif WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /SG`t,° DISPOSAL FLD. PROP. LINE Jr <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 /> ^\ 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 C1 Well Diameter Sealing Material ftop 50'1 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION © REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is \ j <br /> available within 200 feet.) <br /> !f Installation will serve: Residence— Commerciai_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TAK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total lengthlsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size 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 in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner„gr 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 required in ctions. Complete drawing on reverse side. <br /> Signed r Title: ' 7 Date: ._ <br /> i FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ Date Area <br /> ni <br /> Pit or Grout Inspection by Date Final Inspection by DatV- P- <br /> o <br /> Additional Comments: <br /> 1 17-Y <br /> ❑ Stk 466.5781 1�Lodi 369-W1 0 Manteca 104 ❑ Tracy <br /> Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE <br /> INFO <br /> + EH 13-24Inev,I/Stl <br /> EH 1426 <br />