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APPLICATION,FOR PERMIT <br /> d <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ; <br /> 1601 E. HAZE T ON AVE.,;STOCKTON, CA s <br /> Telephone'(209) 46616781 <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> (Complete in.Triplicate) <br /> i <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 Lot Size PM <br /> Owner's Name" Address Pr Ss'a3 S 9 Phone 78 <br /> } I <br /> Contractor Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> 'h <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FID. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS . <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS r <br /> F. <br /> ❑ Industrial ❑ Open-Bottom�,,,,..,� Mani_eca,,.,�.,.,,.,.Dia._ot„Well.Excavation- Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I Specifications � } <br /> ❑ Public 3ti ❑ Other ❑ Delta Depth of Grout Seat Type of Grout <br /> LlIrrigation f, --Approx., Depth C1 Eastern Surface Seal inystalled by "Q <br /> Repair Work Done C] Type of Pump '� H-P. i-li `state Work bone <br /> 1/ ._,,. I I <br /> Well Destruction Ltf Well Diameter �o a Sealind.Maierial (top 501 <br /> Fa � ti k # <br /> Depth Filler Mat4nal (Below 501.) 1' i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑. DESTRUCTION ❑ (Noseptic system permitted if public sewer is <br /> available within 200 feet. <br /> $ jl <br /> Installation will serve:: Residence Commercial Other ' <br /> Y_' n <br /> Number of living units: Number of bedrooms li 1 <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK ❑ Type/Mfgi Capacity No!Compartments E <br /> PKG. TREATMENT PLT. ❑ I! Method of Disposal <br /> i Distance to nearest: Well Foun ation'! Property Line 3 <br /> LEACHING LINE ❑� No. & Length of lines ?a ; ilk Total length/sizel <br /> FILTER BED ❑ Distance to nearest: Well ':'f Foundationf Property Line <br /> SEEPAGE PITS ElDepth E Size Number I <br /> SUMPS ❑- Distance to nearest: l-WellFoundationProperty Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District.. . iji I <br /> E 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 subiect to workman's compensationf 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. , ,lI <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X� . s"v Title: ® �� Date: �'l G —� 7 <br /> s� FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date [ ��`( 7 Area Q <br /> Pit or Grout Inspection by Date Final Inspection by �r Date <br /> Additional Comments: "� / _ �` <br /> ❑ Stk 466-6781 J❑Lodi 369 TTS - Manteca 823-7104 ❑-Tracy 835-6385 f r �yJ <br /> Applicant- Return all copies to: Environmental ealth Permit/Services.-1601:E. Hazelton Ave.-P.O. Box 2009, Stk., CA 95201CK <br /> D <br /> FEE ;SI AMOUNT DUE AMOUNT-REMiTTED SH i RECEIVED BY DATE PERMIT NO. <br /> INFO CA <br /> 1n $ <br /> + EH 13-24(REV.I 11 5) I ?'- 4343,5 �7- 127,1131 <br /> , <br /> EH 14.26 <br />