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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <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 /> J S9 � 1 <br /> Job Address d.+L/ City Lot Size PM <br /> 44 Owner's Name 7 <br /> 1'-� "�'�r�'--� -r�t-� s5 "a. Phone <br /> r _ <br /> Contractor dress L icense N) , Phone tom" <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> tr. 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-1 Public n Other [1 Delta Depth of Grout Seal Type of Grout—­ <br /> I <br /> rout_ _I I Irrigation —Approx. Depth I I Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> ` Installation 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 13Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ��1 /� Method Disposal <br /> Distance to nearest: Wellz(_17_f,— Foundation l� Property Line <br /> sex LEACHING LINE ❑ No. & Length of lines ' ^ ^ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well /--z.�-z.� Foundation o,L Property Line _ <br /> r <br /> SEEPAGE PITS 11 Depth Size Number <br /> MP Ll 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 /> r',,x 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, 1 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 /> cenifies 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 st cal all uire i�1 ns cirons. Complete d Qing averse side. <br /> Signed X G Title: 1--1=7g7L Date: <br /> ir. FOR DEPARTMENT USE ONLY �] <br /> Application Accepted by S� Date "`b - Area <br /> ` Pit or Grout Inspection by Date Final Inspection by '��� .�'+ Date <br /> A ditional Comments: <br /> Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> ` A plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOU`NT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> `E14 H 1�.76(REV.,/xal ^/0 ` U( <br />