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APPLICATION FOR PERMIT '" I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL"TON 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. <br /> L1 ` r� i <br /> Ski S Solo 0 + ��� Ci �OOC z ` Lot Size PM <br /> Jab Address � ' <br /> y <br /> Owner's Name i�j 01-� , M�1 R1 r O 11 S�-o[�I Address Phone <br /> Contracto nE1 J�shs - Address . ��X License No, LY1SyPhone� � } <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT NL DESTRUCTION ❑ <br /> PUMP INSTALLATION 171 SYSTEM REPAIR EJ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK `!f � SEWER LINES — DISPOSAL FLD 2 S-0 PROP. LINE <br /> FOUNDATION 7d�r AGRICULTURE WELL -r OTHER WELL PITS/SUMPS -1-1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El industrial ❑ Open Bottom C1 Manteca Dia. of Well Exca tion Dia. of Well Casing <br /> ❑ Domestic/Private S Gravel Pack Cl Tracy Type ofCasing SpecifrcationsQQ�� r 1 <br /> IN Public ❑ Other 'r N Delta Depth of Grout Seal Type of Grou1"4 ' <br /> ❑ Irrigation __4pprox.,Depth LlEastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump t H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top.501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve:-' Residence_ Commercial_ Other V <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 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 ❑ Depth Size Number <br /> SUMPS ❑ 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."Contractors hiring or sub-contracting signature <br /> certifies the foil wing:"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 fornia." <br /> The applicant st call for all red inspections. Complete drawing on reverse side. O <br /> Signed Title: QA)Cc- Man -�r Date: _Zai <br /> V <br /> FOR DEPARTMENT USE ONLY g <br /> Application Accepted GA:�412d Date m f"02`-8 [ Area 0 <br /> Pit or Grout Inspection y Date final Inspection by Date <br /> Additional Comments: t� AAJ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3631 ❑ Manteca 89J-7104 ❑ Tracy 83 . <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., Box 2009 tk., A 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT°'NO. A <br /> m INFO <br /> + EH 1324(REV.1/a 5) <br /> EH 14-2e <br />