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g APPLICATION FOR PERMIT L <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (20 9) 466-6781 <br /> III ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby malde 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. I p <br /> Job Address t II 3 t ... b• �.� <br /> City Lot Size 1 Xs- PM <br /> Owner's Name -D ullA-13, tVPrh- 4c4C Address4'0150 . 'Y I,,I SZ=01300Phone Y&A <br /> Contractor ]4r:5c–" Address i <br /> License No. Phone <br /> TYPE OF WELL/PUMP:1� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLp, PROP. LINE' <br /> 19. FOUNDATION AGRICULTURE WELL_. OTHER WELL PITS/SUMPS �' x <br /> il. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � " <br /> - ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FJ Public I' ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation i —11Approx. Depth ❑ Easte_rn Surface Seal Installed by <br /> Repair Work Done ❑; Type of Pump <br /> H.P. State Work Done_ <br /> Well Destruction ❑ • Well Diameter Sealing Material Itop 50'1 <br /> Depth j Filler Material {Below 5011 <br /> TYPE OF SEPTIC WORK-. NEW INSTALLATION ❑ REPAIR/ADDITION)❑, DESTRUCTION (No septic system permitted if.public sewer is - <br /> �� available within 200 feet.) J t <br /> Installation will serve: !`Residyence_ Commercial! Other t <br /> Number of living units:� Number of bedrooms d <br /> Character of soil to a depth of 3 feet: Water table depth <br /> 0.SEPTIC TAN!( ❑ TEype/Mfg t Capacity-----L_ No. Compartments <br /> PKG. TREATMENT PLT. <br /> I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ­7777— <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Li Depth Size � , <br /> I Number <br /> SUMPS D Distance to nearest: WeII I <br /> wFoundation -Property Line <br /> DISPOSAL PONDS ❑ aye 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 Sari Joaquin Local Health District.. <br /> Home owner or licensed a'gent'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- l <br /> tion laws of California." <br /> The applicant st calf iQr re uire i spection . ZpTle drawing on reverse side. <br /> 'M <br /> KSigned Title:. (NAS <br /> �'" Date: <br /> FOR DEPARTMENT USE ONLY <br /> 1 _ <br /> Application Accepted by ' Date S Area <br /> I '- V <br /> Pit or Grout Inspection b N # Date Fina! Inspection by Date Z�n� <br /> I Additional Comment - <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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED HY DATE PERMIT NO. <br /> CASH <br /> + EH13-24(REV.tins) 'IM f , S7 1 7 <br /> �-X <br />