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I <br /> APPLICATION R 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) ''; y <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 Ryles_and.Regulations of the San Joaquin <br /> -Local Health District. 41' <br /> Job Address ��� C70�`Y f� '� r1+��'.?* -A f �f� <br /> ,. City Lot'Size PM <br /> Owner's Name�� /'��� �•Y f "tAddress - - Phoney e. �B�T <br /> Contractor d0 RSV Address—Z� _af C X /\D License No. to Ro Phone <br /> ng <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 /> 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 l <br /> f. ❑ Public ❑ Other , ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth- ❑'Eastern- Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> V. Well Destruction Xi Well Diame er 1 7 Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 r r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION, o septic system permitted if public sewer is <br /> -available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other it1 <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 Ll ' Method of Disposal <br /> G. <br /> Dista nce`to.nearest: Well ' + Foundation. + Property Line <br /> LEACHING LINE ❑ No._& Length of.lihe's�'- Total length/size <br /> FILTER BED ❑ Distan a fb nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ -Depth- Size Number <br /> SUMPS' E.I. Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ '`-�-- + <br /> I hereby certify that I have prepared this application and fhat ilia-work`wiI0be`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•a'ent's si naiure cerbfi4 the followin M.. <br /> g g g: "1'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-b--ecome 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"ofthe:work-for mi1iiEh't6is permit is-Issue)),I sltiall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t call for all required inspections. Complete drawing on reverse side. <br /> • Signe- Title: ' Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted-6y" <br /> Pit or Grout Inspection by Date X Fiiia I Inspection by� Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> i 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 t AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT''NO. <br /> + EH 13-24(REV.1/8 5) !' <br /> EH 1426 <br />