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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 /> 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 /> r-14,4—F AIC14 <br /> Job Address f��-� .�. Qr�^Lt_T 994? City C--,41-r Lot Size PM <br /> Owner's Name Aio.TF'-m 5 L acr,ChAddress IZ2 Vl0 15Phone 4K <br /> Contractor ! 4ddress 1&11Z_S!L is &V`*4 cense No. Phone <br /> 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 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 Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---4pprox,. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump 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{ - <br /> available within 200 feet.) <br /> Installation will serve:' Residence Commercial— Others- <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth 4-- <br /> SEPTIC TANK Xi Type/Mfg Capacity No.No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> .. t <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 /> 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. 6 <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."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 must call fo all required inspections. Complete drawing on reverse side. <br /> L <br /> Signed X Title: Date: -- <br /> 0 DEPAR ENT USE ONLY <br /> Application Accepted by Date Area <br /> {� I <br /> Pit or Grout Inspection by Date _ Final Inspection by / Date O <br /> Additional Comments: i <br /> Stk 466-6781 ❑ Lodi 3621 ❑ Manteca -7104 ❑ Tracy 835-6385 i <br /> Applicant- Return ail copies-to; Environmental Health Permit! ewices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CAS <br /> RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24{REV.1/65) -70 -001 �� J - lin 3c.,�3�P P7-7(-P <br /> EH 14-29 IYV ,/ I <br />