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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 4456-6781 <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 . City Lot Size E3 /� _ PM <br /> Owner's Name A/�R,f X � /rdlmll 57-5t�0 /Yl(AArT?05 V�Phone <br /> Contractor Addres I 101 iLlIfW License N ���Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 /> I <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 /> 1­1 Public F1Other F1 Delta Depth of Grout Seat Type of Grout _. <br /> ! I Irrigation _..Approx. Depth i I Eastern Surface Seal Installed by _, <br /> Repair Work Done 0 Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 ; <br /> IF <br /> I <br /> TYPE OF.SEPTIC WORK: NEW INSTALLATION I] REPAIR IADDITION DESTRUCTION l I (No septic system permitted if public sewer is � <br /> . available within 200 feet.) <br /> Installation will serve: Residence& Commercial_ Other j <br /> Number of living units: _-/__ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ 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 linesTotal length/ ,e <br /> / <br /> FILTER BED ❑ Distance to nearest: . Well Foundation _ Property Line nR` <br /> SEEPAGE PITS JK Depth �S Size_ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation. 5—#e Property Line <br /> 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 /> 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, 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 i pe tions. Complete drawing on reverse side. <br /> Signed Title: 1�-Q I;Z�� <br /> e..... Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date tob V Area JJ <br /> Pit or Grout Inspection by Date Final inspection by Date(e /-1 <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 M, Stk.,'CA 95201 <br /> I <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH CK 9 c Vm BY HATE PERMIT NO. <br /> ♦ EH 13-24 IAEV.t i x 51 -oo 190*77160 <br /> EH 14.29 r �+f L V <br /> �- i <br />