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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E, HAZELTON AVE., STOCKTON, CA <br /> I 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. 7862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. �+ F� <br />? Job Address x 3 1] O S e'r i7fa. <br /> City_�Yi'9'�-� Lot Size PM <br /> Owner's Namet <br /> Y� � � Address '1 d 5 Tt° <br /> t Phone p'3�"'.5'3�3 <br /> t 1 Contractor 'T!07-30/}° f So/✓ Address 4042 V!B V^J <br /> License No.!yXf''9/ Phone Sigh' J:> <br /> i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 'D " <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA <br /> CONSTRUCTION SPECIFICATIONS <br /> L1Industrial ❑ Open Bottom O Manteca Dia. of Well Excavationg <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation ­Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50'} f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I 1 (No septic system permitted it public sewer 1s <br /> $ available within 200 feet.) <br /> k Installation will serve: Residence Commercial_ Other <br /> Number of living units:� Number of bedrooms <br /> Character of soil to a depth of 3 feet: -------"-- <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No" Compartments <br /> PKG. TREATMENT PLT. ITMethod of Dispose! <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE R No. & Length of lines Total length/size A00 <br /> t FILTER BED ❑ Distance to nearest: Well 19?a' Foundation _ �® _ Property Line 10 <br /> lZRA <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> F.' DISPOSAL PONDS ❑ <br /> 1 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 /> rulesand regulations of the San Joaquin Local Health District. <br /> P <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 /> Ftion laws of California." - <br /> The applicant mus call for all required inspections. Complete drawing on reverse side. <br /> Signed X Titre: Data: r i`9P <br /> y FOR DEPARTMENT USE ONLY <br /> J Application Accepted by �i/ 90 Zl� <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by pate ' 9,9 <br /> Additional 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 /> E <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO C SH RECEIVED BY DATE PERMIT N0. <br /> I+ EH 13-24 iREV.I/rtSY ��r 7�_ r �,� �/ f /� �o �0 <br /> EH 14-2fl ,- fl `/CJ ��s <br />