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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRILCT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . <br /> (Complete in Triplicate) FILE COP <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 L CityXy Lot Size3.27 AG 3,( Pm <br /> VkjeoloV'�Acldress <br /> Owner's Name 1�p '` �'G Phone f / v <br /> r <br /> // ff <br /> Contractor • t ddress 2216) C-_ License NoK Phone J / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYS EM REPAIR U OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE LINE DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRIC LT E WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE 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 ❑ Other n Delta Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation _Approx. Depth 1 1 Eastern Surface Seal 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 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> .,_ available within 200 feet.) 1 <br /> Installation will serve: Residence Commercial_ Other 1 <br /> Number of living units: Number of bedrooms Z n <br /> Character of soil to a depth of 3 feet: r Water table depth (�1 <br /> SEPTIC TANK ❑ Type/Mfg l Capacity? 11 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method o I <br /> Distance to nearest: Well / _ Foundation Property Lin O <br /> LEACHING LINE ❑ No. & Length of lines To al length/size <br /> FILTER BED El Distance to nearest: Well Foundation` a Property Line <br /> —if �— — <br /> SEEPAGE PITS [ I Depth Size Number <br /> SUMPS LI Distance to nearest: Well undation- (� Property Line <br /> DISPOSAL PONDS [1 <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( ist all foraN Fequired i spections. Complete drawing on reverse side. I <br /> Signed X 1 s� • Title: &f AA"nJ"n --- Date: <br /> �DEPARTMENT USE ONLY <br /> Application Accepted by ���pa1� d�1 t� Date_mac Area <br /> Pit or Grout Inspection by Date Final Inspection b� ( , Data 11 <br /> f <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 t <br /> FEE OUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> EH13-24 IREV.i �5 <br /> EH 14-2e l / <br />