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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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. <br /> Job Address City Q n• R t pON I�IPalV Lot Size � � 'jPM <br /> Owner's Name "��y S Address S�Me Phone <br /> Contractor • ' M `AR I'Le Address IS-(')' AV License No.�y f$ Phone <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 <br /> 1'1 Public fl Other n Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done Ai_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 `V <br /> Depth Filler Material (Below 501 C <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION lerREPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_n Other <br /> Number of living units: Number of edrooms L <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg t Capacity OV No. Compartments r <br /> PKG. TREATMENT PLT. ❑ , Method of Disposal <br /> Distance to nearest: Well 2 Foundation Property Line <br /> LEACHING LINE No. & Length of lines - 4 Total length/size <br /> r r <br /> FILTER BED ❑ Distance to nearest: Well 1 V Foundation �V Property Line i O <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS U1 <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. <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 thaJthe orrpance of thework for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant II for all qutions. Complete drawing on reverse side. <br /> Signed X - Title: DAL)kue-4 _ I <br /> Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by ` Date Area r, <br /> Pit or Grout Inspection by Date Final Inspection by Date G 2r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi/369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,-P.O. Box 2009, Silk., CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NEH 13-24 O. <br /> • EH U-29 IREV.r _ O,.o o �-7� <br />