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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �«. <br /> In Jr (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. <br /> Job Address L� — k Srn.�i?`L; . iN /cam _ City SR3U .Lot Size D 14[� PM <br /> Owner's Name ��rAddress <br /> - Phone n <br /> V\ i <br /> Gontrac#or <br /> Address Jf 9CTa -k A License No.IZK606 phone *96 —,9'6&R <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Qr <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHER El [\] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE \} > <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca -gw..Dia:.of:Well Excavation Dia:ofd Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing --- .. Specifications <br /> ❑ Public ❑ Other ❑ Delta <br /> Depth of Grout Seal Type {Grout l� <br /> Cl irrigation _J4pprox. Depth ❑ Eastern Surface Seal Installed by 1 <br /> Repair Work Done ❑ Type of Pump l H.P. StaielW&Ik Done <br /> Well Destruction ❑ Well Diameters Sealing Material (top 50') \ <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO No septic system-perlrnitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: I Water tal3le depth , <br /> SEPTIC TANK ❑ Type/Mfgt Cap'aity; '+- No. Compartments f <br /> PKG. TREATMENT PLT. ❑ t <br /> r"' Method of Disposal <br /> Distance to dearest: Well Foundation p I bperty'Line _ <br /> A <br /> LEACHING LINE ❑ No. & Length of lines ' '" <br /> Totallengih/size. <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 1 � t <br /> SEEPAGE PITS ❑ Depth 1 Size Number— <br /> SUMPS d Distance to nearest: Well Foundation- Property Line <br /> DISPOSAL PONDS I l i <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 /> Nome owner or licensed agent's signature certifies the foNowing: "I certify that in the performance of the Work far 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 Califomia."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,11shall empiloy persons subject to workman's compensa- <br /> tion laws of California." 1(4 Aensa- <br /> The appfl t must call for all Aequired inspections. Complete drawing on reverse side. <br /> I <br /> Signed Titl Date:` ? <br /> ` FOR-OEPARTME11111f E ONLY <br /> Application Accepted b DateQ <br /> Area_ <br /> Pit or Grout Inspection Date Final Inspection by Date y <br /> Additional Comments: <br /> ❑ Stk 466-6781 - ❑ Lodi 389-3621'4 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Retum all copies to: Environmental Health PermOServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 " <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMITINO. <br /> INFO <br /> .x. <br /> + EH 13-24(REV,1/85) � 5. -- <br /> EH 14-2e 3 CtA'7--25 0 <br />