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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 /> f <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED__ <br /> (Complete in Triplicate) 17p�f11 �' �'«' + <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 i <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. ��r �� <br /> ► I�-L{l � City <br /> Jab Address <br /> Oer's X5.11 r nNfll -.i Address __JCS l-� Phone <br /> wn <br /> Name ! <br /> d?Drj <br /> Contractor Address •cens`e�No -of„CC�''tc�i�_-'Phone <br /> TYPE OF WELL/PUMP: N WELL C WELL REPLACEMENT t-1 DESTRUCTION O <br /> Illtwill <br /> r w e GL <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 . OTHE <br /> SEWER LINES DISPOSAL FLD._-.— P OP. LINE - <br /> DISTANCE TO NEAREST: SEPTIC TANK __ PITS/SUMPS — <br /> FOUNDATION _ _ AGRICULTURE WELL OTHER WELL - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Wel! Casing �. <br /> C Industrial O Open Bottom U Manteca Die. of Well Excavation <br /> T e of Casin C Specifications_ <br /> O Domestic/Private Qfl Gravel Pack Ll Tracy yp g— Type of Group'--. <br /> 11 Public i Other LI Delta Depth of Grout Seal YP <br /> I . Irrigation _Approx. Depth I Eastern Surface Seal Installed by - <br /> Repair Work Done i-]--^ Type of Pump <br /> - •-�--H:P:- _ — State Work Dane--_ <br /> Well Destruction '/F-1 Well Diameter Sealing Material ttop 50'I -- <br /> 7yte...-fi^n !,J!-ei Depth� fillet Material (Below 50'1 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION-I1`�-REPAIR/ADDITION t I DESTRUCTION t (No <br /> ailabhelwithine200(etlt}ed if public sewer isyf <br /> Installation wilt serve: Residence .— Commercial Other . -- <br /> Number of living units: Number of bedrooms <br /> Water table depth _- <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK O Type/Mfg _ Capacity No: Compartments _ <br /> PKG. TREATMENT PLT. Cl Method of Disposal _. <br /> Distance to nearest: Well_-_ Foundation__ Property Line <br /> LEACHING LINE Cl No. & Length of lines __ Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation _— Property Line <br /> SEEPAGE PITS 1 1 Depth 1Size ` Number <br /> SUMPS ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS"""'❑ ` <br /> I 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. i - <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 ins a tions. Complete drawing on reverse sided//yJf`^ ♦9 � <br /> Title: <br /> Date: <br /> Signed X-- t <br /> 1 t FOR DEPARTMENT USE ONLY <br /> + Application Accepted by 3 Data ` Area <br /> _ <br /> Date) Final Inspection's Date <br /> Pit or Grout Inspection by � „ <br /> j Additional Comments: r <br /> I - <br /> G Stk 466-6781 'E7 Lodi_369-3621 Y � � Manteca. 823.7104 O Tracy 835-6385 <br /> M Applicant - Return all'copie+s to: Environmental Health Permit/Services 1601 E. Hazelton,Ave., P,O. Box 2009, Stk.�CA 95201 <br /> t FEE. AMOUNT DUE AM66NT REMITTED C _ rREC£IVED BY DATE PERMIT NO. <br /> f tNFO Ears <br /> + EH 13-241REV.1in51 C�, 15" <br /> EM 14-25 <br />