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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1601 E. HAZEL T ON 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 325b (� ' <br /> -- LAa4l r City Lot Size PM <br /> Owner's Name C Address 1/� S�---7 / x p / <br /> �.��C (.�i .� �W?LwiF <br /> Phone b <br /> Contractor C Address 2)32—)_E /r <br /> - KL License No.51 Phone <br /> j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LA <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 Specificati s <br /> I'1 Public Other ❑ Delta Depth of Grout Seal Type of Grout <br /> i I i Irrigation t5_Approx:Depth I ) Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done W t <br />+ Well Destruction ❑ Well Diameter Sealing Material Itop 50') W(-r:I1•}- 62'e- <br /> Depth <br /> 7 Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permilted if public sewer is <br /> i available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> i Character of soil to a depth of 3 feet:= Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments W <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 4 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> nrSUMPS ❑ Distance to nearest: Well Foundation Property Line <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$trict. <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 note <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 <br /> compensa-tion laws of California." <br /> The applicant m call for required inspections. Complete drawing on reverse side.. <br /> Signed X Title: M <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ��Q 1 I <br /> Date Area <br /> Pit or Grout Inspection byDate Final Inspection by Date <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, Stk., CA 95201 <br /> F <br /> FEE AMOUNT DUE <br /> INFO f AMOUNT REMITTED G SH RECEIVED 13Y DATE PERMIT'NO. <br /> I <br /> ­EH 13-24 iREV.tiksl <br /> EH 14-28 , <br /> _ F <br />