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APPLICATION FOR PERMIT 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-Ml <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 Na. 1862 for well/pump and the Rules and Regulations of the San Joaquin" <br /> Local Health District- „ <br /> Jab Address /10 iJ �• Gr r P+,S S L "City` Lot Size CJr �SPM <br /> - Owner's Name R, t Address Phone <br /> Contractor �. i ddres License No. Phone � �s <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT El DESTRUCTION L) <br /> PUMP INSTALLATION El REPAIR OTHER 11 <br /> DISTANCE.TO NEAREST: SEPTIC TANK .SEWER'LINES "T.�� DISPOSAL FLD. PROP. LINE <br /> _ r::r�'•^^-^ �'-�""�" <br /> �" FOUNDATION S 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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout- <br /> -0'I ritigation'— <br /> rout-❑'Irrigation`"""°"" "'"APPro-x-�D60tti" "❑'Eastern^` "Su"rface Seal"lnsfalled'by { <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Mgerial (Below 501 - <br /> E TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> k available within 200 feet.1 <br /> Installation will serve: Residence L�Coriimercial Other f <br /> Number of living units: _L_ Number of bedrooms "YI <br /> I i <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK ®/type/Mf9 } Capacity No. Compartments4=j� I ` <br /> r PKG. TREATMENT PLT. ❑ I Method of Disposaa <br /> f <br /> Distance to.nearest:-.,—.WellI QD�Foundation Property Line/fid <br />+ Total length/size <br /> LEACHING LINE ��. & Length of"li es <br /> FILTER BED._ s 'r ❑1 Distance'o_nearest-. "'b Well Foundation Property Line <br /> SEEPAGE PITS r GI�Oepth l �' ' Size i�1sa Number <br /> ..SUMPS ❑ Distance to nearest: Well� •!" Foundation . Property Line <br /> — <br /> DISPOSAL PONDS ❑ <br /> hereby certify that l have prepared this application",and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> G rules and regulations of the San Joaquin Local Health District: . <br /> Home owner or licensed agent's signature ceq'fi6's the following:,"1-certify that in the performance of the work far 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 /> certf <br /> following: "I rtify that in the rformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> do California." *"s <br /> Ths all for all eq ed in ctio mpl e'drawing on verse si �0 <br /> c. •: //r' <br /> Signed Title: Date: <br /> l FOR DEPARTMENT USE ONLY J <br /> Application Accepted-by- Date L G r Area Q <br /> Pit or Grout Inspectio y Date Final Inspection by Date <br /> Additional Comments:.- <br /> ❑ Stk 466-6781,/ El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 8385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ' 1FEEN O AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13-24 TREY.1/1I <br /> -�� <br /> E1114-25 <br />