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APPLICATION FOR PERMIT <br /> SAN JOAQUI4N LOCAL HEALTH DISTRICT j <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> '""-Telephone (209) 466-6781 <br /> PERMIT EXPIRES I 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 /> If <br /> Job Address ,:, !^r C-T ? (f <br /> . ILICity Lot Size <br /> PM <br /> r } <br /> Owner's Name 1 <br /> Address- Phone <br /> ;? <br /> Contractor L, !Address ��� <br /> License No. Phone <br /> TYPE OF WELL/PUMP: (NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑i . SYSTEM REPAIR OTHER ❑ <br /> • SEWER <br /> DISTANCE TO NEAREST: SEPTIC TANKLINES <br /> # <br /> DISPOSAL FLD. PROP. LINE <br /> f FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ! ❑ Open Bottom *.❑ Manteca ' 0-'tt Dia: of Well Excavation <br /> - .�. <br /> f�Domestic/Private --"" ❑'Gavel Pack--=�-�j Dia. of Well Casing <br /> Trecy --rType af=Casing�-"""�' -' - - -- <br /> ❑ Public a `t ❑ Delta Specifications <br /> _f'''❑ Other Depth of Grout Seal - <br /> ❑ Irrigation _,q Type of Grout <br /> Vpprox. Depth ❑ Eastern ' ans <br /> Repair Work Done ;' Type of Pump dace S l Italled by H.P. <br /> State Work Done � <br /> Well Destruction- Q Well Diameter Sealing Material (top 50'}_ <br /> 99.9.9) Depth Filler Material (Below 50'} r` J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �✓ <br /> Installation-will senre: Residence— Commercial, Other available within 200 foet.l <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK� Water table depth CJ Type/Mfg Ca acitY No. Compartments <br /> P <br /> PKG. TREATMENT PLT. ❑� <br /> e` . Method of Disposal <br /> Distance to nearest: well. Foundation Property Line f <br /> LEACHING LINE g'" ❑ No. & Length of lines Total length/size } <br /> FILTER BED r lip Distance to nearest: Well ? <br /> r Foundation JProperty Line <br /> SEEPAGE PITS,^ ❑ Depth - Size Number <br /> SUMPS rte_. a',Q411 <br /> Dis'tance to nearest: Well ' <br /> Foundation 'Property Line <br /> DISPOSAL PONDS•., ,/Fl <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: p r -... <br /> em to an "I certify that in the performance of the work for which this permit is issued, I shall not , <br /> ploy Y person in such manner as to become subject to workman's compensation laws of California.- <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 /> } <br /> The ap I' us call for at] req- inspec ns. C plete drawing on rev side. <br /> Signed X <br /> Title:r <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 0y <br /> Date Area <br /> Pit or Grout Inspectio - Date * i f s`Final Inspection by <br /> I + Date V "'� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 3699-3621 j. ❑ 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 6 CK <br /> INFO CASH % k RECEIVED lay DATE PERMIT'NO. Y <br /> + EH'1 -24IREV.S/xsl t:a0 - l -2(AEH 1428 <br /> - ' w <br />