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APPLICATION FOR PERMIT ' <br /> • SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> -` ;- 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 O[PlyPERMIT 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 Distrix?. r � 7 <br /> f Job Address � `C h r D City ""�nLai Size PM! <br /> Owner's Name I ' ' 1 � LS IQ S Address ��Lt✓ - f�1C�gCk Q ('I o Phone <br /> %) <br /> Contractor r ,Ad l��f�ldde �i E L� License No. `_�S._��11 Phone_ S `'? <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTI,ON ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.;LINE i <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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth `.❑ Eastern Surface Seal Installed by e r T <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction _'L' Well Diameter Sealing Material (top 501 <br /> r; <br /> �., Depth Filler Material (Below 501 ---' � f *"�' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Q <br /> ' available within 200 feet.) <br /> Installation will serve: Residence '- Commercial= Other �l <br /> Number living units: _ Number of bedrooms <br /> 'Character of soil to a depth of 3 feet: �i Water table depth <br /> SEPTIC TANK El Type/Mfg der Capacity No. Compartments <br /> PKG. TRE�TMENT PLT. ❑ , � Method of Di*poral <br /> 1 <br /> Distance to­neaiest: Wel! :ASD Foundation-_[-a_- Property Line <br /> t { <br /> LEACHINGtLINE ❑ No. &!Length of lines Tetal'length/size <br /> { FILTER BE15 y ❑ Distance to nearest: Well Foundation Property Line <br /> b <br /> €v <br /> c <br /> SEEPAGE PITS ❑ Depth Size L �Nucb,er <br /> SUMPS I. ❑ Distance to nearest: Well Foundation Property Line_..-tqb_,__ <br /> DISPOSAL PONDS 1. ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and <br /> rules and regulations 4the San Joaquin Local Health District. it <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 /> I 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: "Ircertify 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 C lifornia. <br /> I The appfica must call for al it inspection Complete drawing on reverse side. ` r <br /> i Signed X Title: O � L Date: • <br /> EPARTMENT USE ONLY <br /> tion Accepted by Date 60`7��._ Area <br /> Pit or Gr t Inspection by /1:; Final Inspection b Date_ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantaca 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 /> FFEE ( <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> a EH t3-24(REV.t/H 5) �--'7� , 10/ -717 <br /> EH 14-28 / <br />