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APPLICATION FOR PERMIT � . <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.,_STOCKTON, CA <br />( Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> D . ~; <br /> Y. <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 C&unty Ordinance No.549 for sewage or No. 1862 for well/pump and the <br /> Local Health District. Rules and Regulations of the San Joaquin <br /> f <br /> Job Address sty Lot Size <br /> PM <br /> P <br /> Owner's Name Addresst.c.�rz�' Cys A- <br /> •�_. �. •- 1 0,`,.t �4 � r Phone D l( �► <br /> Contractor Address <br /> License No- Phone <br /> TYPE OF WELL/PUMP: <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION RUCTION ❑ <br /> I -PUMP INSTALLATION [I 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing1, <br /> Specif <br /> L-1 Public ❑ Delta Depth oications <br /> Public Other ! f Grout Seal " Type of Grout <br /> _,_ <br /> ❑ Irrigation Approx..Depth ❑ Eastern ..Surface-Sea] Installed by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done w <br /> Well Destruction '❑ Well Diameter <br /> Sealing Material (top 50') ? <br /> Depth 1 Filler Material (Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> — <br /> Installation within 200 feet.) <br /> Installation will serve: Residence J Commercial_ Other ' <br /> Number of living units: Number of bedrooms t <br /> Character of soil to a depth of 3 feet: I r <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg j Capacity No, Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance totf nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> e1 lSEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ ...Distance to nearest: Well Foundation Property Line . <br /> DISPOSAL PONDS ❑ <br /> 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 blabecome 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- <br /> tion laws of California." ' <br /> The applicant call for all r ired ins -A <br /> i inspections. o I drawing on revers side. <br /> Signed eTitle: .� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byDate 6—� <br /> Area / ¢ <br /> Pit or Grout Inspectionby <br /> q Date Final Inspection by k 1, Date` 0 '7­ <br /> a <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 ii�� AMOUNT REMITTED K � <br /> INFO 7 H RECEIVED BYV-6 <br /> DATE PERMIT�NO. <br /> 'r _ f <br /> + EH 14-241REV.iiasl -C -I , <br /> EH 14-2a' <br />