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APPLICATION FOR PERMIT <br /> (�0 1 Ly S1601 <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> A{ /^ 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> r< PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r '..c (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. �J ^i <br /> Job Address <br /> o�3 2 -V 57 / /L�� i'/N_ City �il'�'� Ltit Size PM <br /> Owner's Name <br /> Ce��0- A Address �� Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 17 WELL REPLACEMENT ❑ DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r <br /> i <br /> pISTANCE TO NEAREST: SEPTIC TANK SEWER LINES —r DISPOSAL FLD. PROP. LINE <br /> FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> P Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type[� Domestic/Private � T Gravel Pack � Tracy YP of Casing Specifications <br /> 1.1 Public n Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. � <br /> A ox. D th I I Eastern Surface Seal Installed by i <br /> Repair Work Done ❑ Type of,Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> pth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: f EW INSTALLATION I I REPAIR/ DITION I I DES RUCTION I 1 (No septic system permitted it public sewenis <br /> av ila a within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Others <br /> f i <br /> i Number ofliving units: —"Number of bei&666ms• — I <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity 17-4IF No. Compartments <br /> 1 <br /> PKG. TREATMENT PLT.❑ � L Method of Disposal <br /> Distance to nearest: Well ^oQ rFoundeti. Property Line `` <br /> 1 <br /> LEACHING LINE I� No. ff Length of lines Tot�l length/size <br /> FILTER BED ❑ Distance to nearest: Well oundatibn Property Line — <br /> . j <br /> EEPAGE PIT I I Depth Size Number i <br /> g�}p — L7 Distance to nearest: Well Foundation Property Line ` <br /> i <br /> I:hereby certify that I have prepared this application and that the work will be done in ac ordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of-the San Joaquin Local Health Oiltrict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the pe rmance of the work for viii"this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's oompensation law(of California,"--Contractor's Firing or sub-contracting signature <br /> gertifies the fallowing: <br /> "I certify th�t in the performance of the work for viihich this Reimit is;issued,1 shall employ persons subject to workman's compensa- <br /> _ _ 1 <br /> tion laws of California." <br /> 4 <br /> The applic t u call for all r quired ing*ctiorkl. Complete drawing on revelse side. <br /> Signed X, � J Title: {{� wi <br /> FO MENT USE'ONLY <br /> Application Accepted by Date Area <br /> I , <br /> Date <br /> Pit or Grout Inspection by Date Final Inspection by �— <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O 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 CASH RECEIVED BY DATE PERMIT NO. <br /> I INFO <br /> a.EHt3741REV.riwsl --- <br /> - <br /> EH 14-26 <br />