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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.i ON AVE., STOCKTON, CA � 1 <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> 1 <br /> l lap ��a ceS7v!�4.+L-2114-- (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 o. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. f 22� �lQaS- 665 �llt�di <br /> Job Address V4 ' «b— Qa5$ <br /> Lot Size PM <br /> Owner's Name 416v,,y,�, —b <br /> :� Address �� Phone <br /> Contractor e.�Y4�el 4ddress F ��� License No.5f4�Phone Ns—evs— <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ . DESTRUCTION EJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 3 OTHER 1 S <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES DISPOSAL FLD. PROP. r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -WtAr� 11 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Well easimy- <br /> 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing �t+ens <br /> F] Public ❑ Other ❑ Delta Depth of Grout Seal <br /> I I Irrigation _.-Approx. Depth I i Eastern Surface Seal Installed by <br /> i <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter I Sealing Material )top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 17 <br /> REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it 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: 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 LJ Distance to'nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS I I depth I Size _ Number <br /> SUMPS D Distance to'nearest: Well Foundation Property Line V <br /> DISPOSAL PONDS ❑ 1 <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 Diltrict. <br /> Horne 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." Contractor's hiring or sub-contracting signature <br /> certifies t!InspectionN <br /> " 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 <br /> The applirequired inspections. Complete drawing on v rse i <br /> Signed X b � <br /> Title: bate: <br /> FOR EPARTMENT USE ONLY <br /> ApplicatioDate <br /> Pit or Grout by Date, Final Inspection b Date t <br /> i <br /> Additional Comments: <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 AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT NO. i <br /> a.EH 13-24(WEV.1/85) I 77 >I <br /> EH 14-26 <br />