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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) } <br /> i <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. Q <br /> Job Address A 44 4 w LA ti el i him i City 4M Lot Size,420 AceES t PM <br /> Owner's Name _ � � ,Address 'Q¢94 [i.✓dUve, Phone <br /> s <br /> <Contractor ,�Qdl11S�i �pn�S Address License No..�r'�3'j:3 Phone <br /> It ,,TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 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 t - TYPE OF WELL---PROBLEM AREA CONSTRUCTION SPECIFICATIONS _J <br /> ❑ Industrial f j ❑ Open Bottom Li Manteca Dia. of Well Excavation Dia. of Well Casing —L <br /> ❑ Domestic/Private ! ❑ Gra0el Packr, ❑ Tracy Type of Casing Specifications S <br /> ❑ Public ❑ Other .. ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ___.�Approx.Depth ❑ Eastern Surface Seal Installed by l <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Weil 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 /> t <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: A_ Number of bedrooms r1 <br /> Character of soil to a depth of 3 feet: L'aw-e" Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Gapacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: I_Well ­--`7 "'Foundation Property Line <br /> LEACHING LINE ■ No. & Length of lines <br /> g L Total length/size �7Q <br /> FILTER BED ❑ Distance to nearest: well - ` "Foundation Property Line i <br /> SEEPAGE PITS ❑ Depth--S" r Size ":s Number <br /> SUMPS ❑ Distance to nearest: Well"%D� i Foundation 7S 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 /> r- 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 becomesubject 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." tip' <br /> The applic nt must call for all required inspections. Complete drawing on re erse side. <br /> Signed � -_..w Title: Date: <br /> FOR OEPARTM NT USE ONLY �f <br /> Application Accepted b47 <br /> y Date �}�fz r} ',P Area <br /> Pit or Grout Inspection by/ Date Final Inspection by 'Z Data j <br /> Additional Comments: <br /> i <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 INFO AMOUNT DUE AMOUNT REMITTED CK 4T <br /> CASH RECEIVED BY DATE PERMIT`NO. <br /> + EH 13-24(REV.i/95) k <br /> EH 1426 'l1 <br />