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APPLICATION FOR PERMIT <br /> SAN-JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA { <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED" <br /> (Complete)n Triplicatel' } <br /> •5-a ..(1' .+ t N c. r :"' ., - <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address /�� 5 U-v'/l T f�i4M' 6 A! _� �� - `I �!°� '' <br /> L4i[y+� 'Lot Size PM <br /> Owner's'Name E 1 Address I/ �C asJ U../V AV-- phone 5 SO <br /> 1 <br /> Contractor y <br /> Ad9res's License_No. Phone } <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONK <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK D d SEWER LINES DISPOSAL FLD.Id CJ PROP. LINE <br /> FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS o j <br /> INTENDED USE , TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing —fes <br /> ❑ Domestic/Private ❑ Gravel Pack ` ❑ Tracy Type of Casing Specifications f+ <br /> ❑ Public ❑ Other I ❑ Delta Depth of Grout-Seal—. �Type of Grout <br /> ❑ Irrigation -L—Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair-Work-Done ❑ Type of Pump i H.P, StatWork`Dcne <br /> WelhDestruction�a Well Diameter /dl Sealing Material (top 50'1 <br /> Depth Filler Materia Balow 50')VXZ � % G,�iA✓E� <br /> F'OF'SEP_T•IC WORK: 'NEW INSTALLATION-❑—REP_AIR/ADDITION.❑� `DESTRUCTION ❑"INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation wl e: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a'depth of 3 ew _ Water fable depth <br /> SEPTIC TANK ❑ i-Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposals""' <br /> i <br /> Distance to nearest: Well undation Property Line <br /> LEACHING LINE ❑ No. & Length.-of lines I length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation LineH { <br /> SEEPAGE PITS ❑ Depth Size Number k <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line 1 <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 District. _ <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance-of the wok 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 must r all r din c' ns. Complete drawing on reverse side. ' t>�. <br /> Signed — -- Title: -- i Date i3r'' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byDate Area <br /> Pit or Grout Inspection by Date Final Inspection by Date ` f <br /> Additional Comments: dT <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 ! <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE ' AMOU//N��T REMITTED +CASH RECEIVED BY . DATE PERMIT"N0. <br /> + EH 14-24fREV.i/e51 �/ v0 TV/o� <br /> EH 14-26 111 1 <br />