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} `. � APPLICATION FOR PERMIT <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.,-STOCKTON, CA <br /> Telephone (209) 4466-6781 <br /> 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 Health District. <br /> Job Address <br /> tai!Q . > r!z�' ;�' <br /> � �7 r.� City `t 1`2C1 Lot Size PM <br /> owner's Name f� ��� Address � ` IV � Phone <br /> F J •' t <br /> Contract 2 tct - h J tc 00Address a License No.371(2,��' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <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 /> f ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I D Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Dane <br /> Well Destruction ❑ Well Diameter Sealing Materia! (top 501 I+}7 <br /> Depth 11 r Material (Belo } 6 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRPADDITION" DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 fest-) <br /> Installation will serve: Residence Commercial Other <br /> } f <br /> 1 Number of living units:---I— Number of droo s <br /> 'Character of soil to a depth of 3 feet: c r 1.�:�- •� --:_ Water table depth Lf c� <br /> SEPTIC TANK ❑ Type/Mfg + Capacity - No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Wel! Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of tines Total'tength/size <br /> ,,rte <br /> o. <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line O4 <br /> SEEPAGE PITS Depth 9S -S ize y Number <br /> SUMPS 0 Distance to nearest: Well 2920 r Foundation /0 ' Property Line <br /> { DISPOSAL PONDS ❑ <br /> 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 /> F. 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 /> a The applicant ust call for all req 'red inspections. Complete drawing on reverse side. <br /> Signed X Title: - Date: r <br /> fill FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> C�/'tl <br /> r Grout Inspection by Date Final Inspection by Date <br /> tional Comments: <br /> ❑ Stk 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 /> P <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED CK f CASH RECEIVED BY DATE PERMIT NO. <br /> EH 13-24 IRfV.+its <br /> . sl <br /> EH 14-28 <br /> / r <br />