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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR FROM DATE ISSUED <br /> r1 (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 Rede ons of the San Joaquin <br /> Local Heal h,,District. '+ <br /> a <br /> Job Address <br /> . City Lot Size PM <br /> Owner's Name ��J� 4 may.. <br /> Address �� Rli V Phone <br /> Contract (., ACdres � �tGS.. � 5 License NoPhone <br /> TYPE OF WELLlPUMP'. r♦ NEW WELL ❑ WELL REPLACEMENT C DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ { <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP'S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> rJ lndustnal ❑Open Bottom D Manteca Dia, of 1+Ve1I Excavation <br /> ❑ Domestic/Private ❑ t Dia.of Well Casing <br /> Gravel Pack ❑Tracy Type of Casing Specifications <br /> 17 Public Cl Other 17 Delta Depth of Grout Seal <br /> f I Irrigation Type of Grout <br /> __Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ R <br /> Well Destruction D Well Diameter Sealing Material (top 50'1 <br /> Depth11 Filler Material (Below ') <br /> TYPE OF SEPTIC WORK: NEIN.INSTALLAT[UN !'I REPAIR/ADDITION ESTRUCTION I I (No septic s.stem s <br /> a Y permitted i(public sewer-is - <br /> Installation will": Residence— Commercial%ther available within 200 feet-) <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: S> 4 p <br /> SEPTIC TANK 'e Water table depth <br /> O Type/Mfg <br /> PKG. TREATMENT PLT.❑ Capacity No. Compartments <br /> � <br /> I Method of Disposal <br /> Distance to nearest: Well t <br /> ,i Foundation ___ Property Line <br /> LEACHING LINENo:'& Length of lines ' <br /> FILTER BED D Distance <br /> length/size <br /> tance to nearest: Welt_ Foundation Property Line <br /> J u�– <br /> SEEPAGE PITSt P <br /> I De th -`_Size Number <br /> SUMPS <br /> Ll Disiance to nearest: Well Foundation3 <br /> DISPOSAL PONDS ❑ Property Line ` <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 111trict- _ <br /> Home owner or licensed agent's signature certifies the following:"1 certify that in the performance of.the work for which this permit is issued, I shall not <br /> employ any person in h mannerjas to become bject to workman's eomperrsation laws of Celifoinia:"'Contractor's-hirin§,orsub-contracting signature <br /> certifies the following: certify that in the pe rf tcelif the work for which this <br /> tion laws of Calif 1 j { permit ismissued,I shall employ persons subiect to workman's compensa- <br /> The appli nt t U for all requlir ns ction . Co ete <br /> ,r 'rig on reverse side. <br /> signed X .t.+t . <br /> Title: Date: <br /> FOR DEPARTMENTfUSE ONLY <br /> �k <br /> Application Accepted by <br /> l Date Araa <br /> Pit or Grout Inspection by t. I <br /> Data Final Inspection by ;Date 4L-7 cJ <br /> Additional Comments; � f <br /> ❑ Stk 466-6781 D Lodi 369-3621• ❑ Manteca 823-7TO4 ❑Tracy'"83x6385 <br /> Applicant - Return all copies to: E»vironmental Health Permit/Sarvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I� a <br /> FEE AMOUNT 0UE CK i <br /> INFO AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT NO. <br /> .EH 731 IRkV.t i A ss 'li ' <br /> EH 1{.16 <br /> �7/1 /f( ` <br /> it �_ <br />