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APPLICATION FOR PERMIT n <br /> V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA Nov <br /> Telephone (209) 466-67$1 v,�ONM <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 'EN <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 e <br /> I Cit <br /> Job Address Lot Size PM <br /> _ _ ji _ <br /> .IXy <br /> X, F <br /> Owner's Name l dress ,4=AeWf1A-� Phone <br /> Contractorad%f � � Address a ,/ -� 44se No. 946Z' Phone r <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 PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca /Dia. of Well Excavation Dia. of Well Casing <br /> Y-ODmestic/Private ❑ Gravel Pack ❑ Tracy \Type of Casing Specifications <br /> M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation ..Approx.,Depth I 1 Eastern J urface Seal Installed by _ <br /> Repair Work Done Type of Pumpj H,P. l7� State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material (Below 50') n <br /> TYPE OF SEPTIC WORK: -NEW'INSTALLATIONLI 1, REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> ! available within 200 feet.) {' <br /> Installation will serve: Residence j Commercial Other <br /> Number of living units: Number of bedrooms ` <br /> / Character of soil to a depth of 3 feet:"� Water table depth <br /> ,SEPTIC TANK ❑ Type/Mfg 1 ; 'Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well ..Foundation Property Line . <br /> I � [ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r' <br /> _ h <br /> SEEPAGE PITS l I Depth F Size - --- Number <br /> SUMPS ❑ 1Distance to nearest: Well Foundation Property Line I <br /> DISPOSAL PONDS �❑ <br /> 1 <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, an <br /> rules and regulations of the San Joaquin-Local Health Di';trict. i <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 I <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." } i <br /> The appl' wt as st c II for all.r ired inspections. Complete drawing reverse side. <br /> Signe Tit Date: <br /> FOR DEPARTMENT USE ONLY M <br /> Application Accepted by Date / APArea <br /> x <br /> i <br /> I <br /> Pit or Grout Inspection by <br /> Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6751 ❑ Lodi 369-3621 EJ Manteca 823-7104 ❑ Tracy 635-6385 r <br /> Applicant- Return all 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 CASH RECEIVED BY DATE PERMIT'NO. 4 <br /> as 1. <br /> +.EH 13.24 IREV.I/n 51 _a 5-- <br /> EH 14-28 w 7 8 O r <br />