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t <br /> i APPLICATION FOR PERMIT <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 1 _ <br /> PERMIT EXPIRES VYEAR FROM DATE ISSUED <br /> r (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 />` 3007 ion �I�/ �'-r. <br /> Job Address 2 <br /> _._ <br /> City M Lot Size PM <br /> Owner's Name ­SCY4,06 T9EAddress .23 ) 0 <br /> 0 2T Phone <br /> Contractor a Addresst/�� <br /> License No, loD,22�_Phone <br /> TYPE OF WELL/PUMP: .. NEW W€LL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER .tf14,04, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> 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 ti <br /> Dia. of Well Casing <br /> C_7 Domestic/Private El Gravel Pack i_1 Tracy Type of Casing <br /> n Public Specifications <br /> Cl Other ❑ Delta Depth of Grout Seal <br /> ! I Irrigation Type of Grout <br /> --Approx,loepth I i Eastern Surface Seal Installed by P <br /> Repair Work Done ❑ Type of Pump H.P. - ; <br /> State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') O <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if 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: PP <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg I <br /> PKG. TREATMENT PLT. ElCapacity No. Compartments <br /> Distance to nearest: Well Foundation erMethod of Disposal <br /> Propty Line <br /> LEACHING LINE ❑ No. & Length of lines N <br /> FILTER BED <br /> ❑ Distance to' Total length/size nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth I Size <br /> SUMPS Number <br /> Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ E Property Line <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: "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 became 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,'f shall employ persons subject to workman's compensa- <br /> tion laws of California." i <br /> The applican ust II for all re wired i pectlons. Complete drawing�on reverse side. <br /> Signed Title. <br /> ECT Date: 8� <br /> FOR DEPARTMENT USE ONLY f <br /> Application Accepted by _ . Date 3g17 <br /> r� a oPit or Grout Inspection by �Date Final Inspection by - Data <br /> Additional Comments: + <br /> N <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 t ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return a I copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> CASH DATE PERMIT'ND. <br /> 3 b <br /> + EH 13-21/REV.t i x 51 <br />