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APPLICATION FOR PERMIT W <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. J //��� <br /> �j5 / .`� — CityOC_ '� Lot Size�2LA-�.0 PM <br /> Job Address �. �_ � <br /> //�'11 <br /> 7Z AI-6`i L���'Ll%Jt Address L- e c' /l /,t �O� e <br /> Owner's Name _ L � `�• <br /> ` u'ytl�/h f� / Phone��,� <br /> Contracts, z Address 0•r,_ License No. , <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT Cl DESTRUCTION U " <br /> PUMP INSTALLATION R 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_ <br /> CI Industrial IT Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing {� <br /> C _Do_mes_tic/Private ❑ Gravel Pack 1_1 Tracy Type of Casing- Specifications ` <br /> i- Public D Other C' Delta t,.Depth of Grout Seal Type of Grout_. <br /> IJ Irrigation JApprox. Depth G Eastern Surface Seal Installed by r <br /> Repair Work Done -❑ Type of Pump _ H.P. _ State Work Done <br /> Well Destruction Ll Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAIR/' DOITION 23- DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> r - available within 200 feet.) <br /> �0 tv1� V <br /> Installation will serve: Residence_ Commercial— Other�.l i <br /> Number of living units: Number of edrooms <br /> Character of soil to a depth of 3 feet: v C��_�_ "`_'� Water table depth <br /> SEPTIC TANK-, D Type!Mfg _ Capacity No, Compartments <br /> PKG. TREATMENT PLT.{J Method of Disposal RNA <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. &Length of lines ,Total length/size <br /> FILTER BED fl Distance to nearest: Well_ Foundation - Property Line <br /> SEEPAGE PITS L' Depth -? —4Size Number <br /> r i p <br /> SUMPS G Distance to nearest: Well ISP_+ 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 aid regulations of the San Joaquin Local Health District. <br /> :..Home owner or,lit:ensed 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 anV person in such mannerras to become subject to workman's compensation laws of Califomia."Contractor's hiring or sub contracting signature <br /> °: =}-"certities'thb follovAng;-''I certify thaYin the performance of the;work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion caws.of.ICaliiomia." <br /> .'.. - <br /> Thd'applicant ust call for e uq (red inspections. Complete drawing on reverse side. <br /> 1-(]�x_J vt <br /> � Signed X \ Title: Date: <br /> FOR'DEPARTMENT USE ONLY' <br /> Application Accepted by" Date_ Area - <br /> 3 Pit or Grout Inspection by Date ( Final Inspection by $ate �o <br /> Additional Comments?-'S%"_'�-' <br /> ❑ Stk 4&fi 6781- 'J'Lodi 368 3621 L7 Manteca 823 7104 ❑ Tracy '835-8385 <br /> Applicant- Return all copies'to: Environmental Health Permit/Services 1601 E- Hazelton Ave., P.0- Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> £N1324(REV.1/651 Oi QB12 F J <br /> EN 1128 <br />