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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA UlN LOCAL HEALTH DISTRICT <br /> Telephohe (209) 466-6781 SAN ]O iv1ENTAL t�L �fH DIVjSEclN <br /> PERMIT EXPIRES 1 YEAR FROM DATE IS5FU <br /> 5 <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 (j'VE ����v ZOo 5+..t of© City x_721 Lot Size PM <br /> Owner's Nam Address Phone <br /> Contractor Aft ""� �' � Address /—��}IG�i l=l��/� _ License No�3��t�J Phone c� a2,7 <br /> TYPE OF WELL./PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Qom, 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 j <br /> J1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation/3 Dia. of Well Casing <br /> /❑ <br /> Domestic/Private J�Gravel Pack ❑ Tracy Type of Casing fTla�C- Specifications - IYAS�. ..�"' <br /> F) Public �O er?404/77/ n Delta Depth of Grout Seal 4w4, J l.Ta Type of Grout <br /> I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by /�L <br /> Repair Work Done ❑ Type of Pump ,jULjm H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing fAalerial [top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTION ! I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other r I; <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Lr Property A Y M E N <br /> RECEIVED <br /> LEACHING LINE ❑ No. & Length of lines Total length/sizel <br /> FILTER BED ❑ Distance 10 nearest: Well Foundation Property. I J <br /> I <br /> SEEPAGE PITS I 1 Depth Size Number T14 I <br /> I <br /> SUMPS ❑ Distance to nearest: Well Foundation Property UW&I SERVICES <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 Di§itict. <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 t call f I req d nspections. Complete drawing on reverse side. <br /> Signed Title: CDD J Date: J <br /> I <br /> �y- FOR DEP N <br /> Application ccepted by Date Area <br /> L r <br /> Pit or Grout Inspection by Date Fi ZInspection by Date <br /> Additional Comments: G �� �g Gfl �/Us,r _r <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5-6385 f-f , LC/Yo <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED FEE <br /> CK H RECEIVED BYDATE PERMIT NO. <br /> +.EH 13-24(REV.r/a 51 <br /> EH 14-26 •-L4 �7l'S 9 Z <br />