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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 '. q <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t (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. y . <br /> Cit <br /> �J/� 6ENIC/'4 y <br /> Job Address II _ � Lot Size <br /> ^^ PM <br /> - - <br /> Owner -- - �L,4cfdress <br /> :s.Name <br /> VA <br /> Contractor__g4ftlj�WAIAddress i License No. - _ a Phone <br /> TYPE OF WELL/PUMP: N WELLX WELL REPLACEMENT ❑ DESTRUCTION ❑ r_ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ -7 <br /> DISTANCE TO NEAREST: SEPTIC TANK A SEWER LINES � DISPOSAL FLD.`� PROP. LINE / z ` <br /> FOUNDATION _. L— AGRICULTURE WELL .r OTHER WELL_ PITS/SUMPS ) <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO ,� II <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I Dia. of'Well Casing <br /> XDomesticlPrivate 5Cravel Pack L1 Tracy Type of Casing Specifications ef4 J <br /> Public H Other Ci Delta Depth of Grout Seal Type of,,Grout i 1 J <br /> I i Irrigation -_..-Approx. Depth l I Eastern Surface Seal Installed by7?�� <br /> ❑ Type of Pump <br /> Repair Work Done H,P. State Work Done <br /> 4 <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 ` <br /> Depth Filler Material 18elow 50') -- <br /> TYPE= OF SEPTIC WORK: NEW INSTALLATION ( 1 REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted if'public sewer is j <br /> available within 200 feet.) <br /> � r <br /> Installation will serve: Residence— Commercial— Other 1 <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/Mfgli Capacity No. Compartments i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> -„ .,... , <br /> -�` :Distance"ta nearest" ” rWell" FounBation -� Property-Line <br /> LEACHING LINE ❑ No. & Length of lines Total lengthlsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation _Property Line <br /> SEEPAGE PITS t I Depth Size <br /> f� Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line� <br /> DISPOSAL PONDS ❑ r <br /> application and that the work.will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this pp � <br /> Y Y <br /> rules and regulations of the San Joaquin Local Health District. ­ . v- �`,i ' <br /> Home owner or licensed agent's signature certifies the following: "I certifythat in the performance.of the work Ifor 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California."' <br /> The applica s I requi i ns. Complete drawing an r v rsk-cide:'� r 1 <br /> Signed X itle: 'r Date: <br /> F � 1 E <br /> F R D ARTMENT USE ON Y <br /> r r G Area r <br /> Application Accepted by Date C <br /> Pit or Grout Inspection by ' Date 'f Final Inspection by <br /> J- Dat M3 <br /> Additional Comments: <br /> ❑ Stk 466-6781 13Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT'NO. <br /> I# INFO <br /> +.EH0 13-241REV.r/H51 i+^ <br /> EH 14-26 rel - 1 <br />