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APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i <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. �F�— r <br /> Job Address ,`70 9V w/ Gtxerte n &44 . City ! Lot Size PM <br /> Owner's Name _31 ' /tiaUL�! T— Address 907- f JOC N Phone <br /> I <br /> Contractor w Address 7 k1t License No.3>jAiL Phone <br /> w WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP- NEW WELL'; <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _. _ SEWER LINES DISPOSAL FLO. Ift PROP.-LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATR S I/ <br /> ❑ I dustrial A❑�/O+pen Bottom anteca Dia. of Well Excavati Dia. of Well Casing <br /> eDDomestic/Private ) Gravel Pack ❑ Tracy Type of Casing �Y Specifications t pro <br /> .{ <br /> ❑ Public J❑_OPer ❑ Delta Depth of Grout Seal �V Type of Grout d4p <br /> ❑ Irrigation JiV__Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump f— H.P. State Work Done <br /> Well Destruction Well Diamet r r Sealing Material (tap 50'1 ce!%�.19T. <br /> / <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if 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 ❑ 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 lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation 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 /> 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 s all for II req ed nspections. Complete drawing on re side. <br /> Signed Title: I� , Date: <br /> FOR DEPARTMENT USE ONLY -7 /� �7"� I <br /> Application Accepted by 1 Date I 36—O 1 Area l <br /> Pit or Grout I spection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracyr 835.6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMWNO. <br /> + EH 13-24{p <br /> EH 1428 EV,1/8 5) <br /> .-.�y <br />