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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE' TON AVE., STOCKTON, CA v <br /> Telephone (209) 466-6781 r' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE W� <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 ed. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Aulek�dd'�iegulations of the San Joaquin <br /> Local Health District. <br /> Job Address % / 3-� /��� Cit <br /> Y, Lot Size ply <br /> � r <br /> Owner's Name _ yY �y,�y Address9/ {� <br /> Phone b — <br /> Contractor IG i� Address b License No./& -)-3 73 Phone T� `4 (� <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 FLO. PROP. LINE CS� <br /> FOUNDATION k AGRICULTURE WELL OTHER WELL PITS/SUMPS \ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> k Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> i Irrigation --Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done r� Type of Pump c� H,P. State Work Done r rTe4 GLQ ire s i, <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION ! I (No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial— Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: r v Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑, ' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ( I Depth Size Number <br /> SUMPS- Li 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 District. <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 must call for alleruired inspections. Complete drawing on reverse side. 1 <br /> Signed X <br /> to: Date: L ` —H <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data ~/ Area /b3 <br /> Pit or Grout Inspection b ata Final Inspection by 3 <br /> Additional Comments: A369 <br /> ❑ Stk 466 6781 ❑ Lo3ti21 ❑ Ma teca 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 AMOUNT DUE AMOUNT REMITTED CK 49 <br /> RECEIVED BY DATE :;7Al �TN <br /> INFO �} CASH <br /> + EH 13.24 1REV. /x 51 �C� O j /—///—Sly <br /> �S� <br />