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APPLICATION FOR PERMIT 0 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 3 / r v City s­V * Lot Size PM <br /> Owner's Name l✓ - Address Phone <br /> _ Contractor,��i�L �A1.4—C.12�6 dress -36D G11).• �� <br /> � _ icense No. a� Phone 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 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 C l a <br /> -F] Industrial - -❑ Open-Bottom- - ❑ Manteca- - -Dia. of-Well Excavation-. - - - Dia. of Well-Casing- <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public i1 Other C] Delta Depth of Grout Seal Type of Grout <br /> E I Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done L7 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material atop 50 <br /> Depth Filler Material (Below 50'1 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ESTRUCTION I i (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence t Commercial Other <br /> Number of living units: __J_ Number of bedrooms G <br /> Character of soil to a depth of 3 feet: hbo bE _Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments I <br /> PKG. TREATMENT PLT. ❑ Method of Disposal I <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 3-44vr--& Length of tines tt Total length/size <br /> r <br /> FILTER BED ❑ Distance to non.nearest: Well Foun atiProperty Line�C� <br /> -:R ) L <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS & BfSiattce to nearest: Well Foundation 5 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 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 Qt1be work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> 7s oCalifornia." <br /> -h..,appli.afnt call r all At etwing o e se side. Date: <br /> FOR DEPARTMENT USE ONLY <br /> n t,� <br /> Application Accepted by " ° �� Date/� Area. <br /> / <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: l It <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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 1 -241REV.i/H5) 77" i2-19-0 �� <br /> EH 144-2f1 <br />