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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> LTelephone (209) 466-6781 <br /> ERMIT EXPIRES TYEAR FROM'DATE ISSUED <br /> (Complete in Triplicate) <br /> r <br /> Application is herebzwithoiaquin <br /> aquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance 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. I <br /> r f <br /> Job Address ' <br /> ��d (!/'�/lCity Lot Size 0 PM <br /> "t <br /> Owner's Name V f t/T 'tiAddress a Phone <br /> IQ-I <br /> Contractor A�S Address- � lL,efJ r-Or � <br /> " '�y�/'� <br /> L erase No. ,P.hone�7` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU �a6N~p <br /> PUMP INSTALLATION ❑ SYSTEM-REPAIR.❑.-- OTHER ❑-. - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTRUCTION SPECIFICATIONS <br /> Ll-industrial ❑ Open Bottom ❑ M a Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing `Specifications <br /> I'1 Public Pte" i=1 Other ' f-1 Delta Depth of Grout Seal Type of Grout _ <br /> i I Irrigation pprox.t Depth l I Eastern Surface Seal Installed by s <br /> Repair Work-Do .Type of Pump H,P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material (top 50') <br /> 3 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l l DESTRUCTION INo septic system permitted it.public sewerTis <br /> s 'available within 200 feet.} <br /> Installation-will serve: Residence_ Commercial— Other <br /> YrNi . <br /> Number of living units: Number of b ooms <br /> Character of soil to a depth of 3 feet:I Water table depth <br /> ''°SEPTIC TANK Type/M# <br /> Q Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ­ Method of Disposal <br /> Distance to nearest:. Well Foundation`7_ ' Property Line <br /> LEACHING LINE ❑ No. & Length of lines ' ''�- <br /> Tatal length/size w� <br /> FILTER BED ❑ Distance to nearest: Well'' Foundation Property Line i <br /> SEEPAGE PITS Depth Siie_ Number <br /> SUMPS ❑1•Distance to nearest: Well.r- Foundation 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 1 <br /> rules and regulations of the San Joaquin Local Health District. - <br /> Home owner 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 arson in su h manner as to become subject torwtlrkman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies ih following: "I certify that in th performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- I <br /> tion laws f Californi <br /> The appli nt st II or all require spections. Complete drawing on r erse side. 7 <br /> / �/ <br /> Signed Title: <br /> Date: _(4 <br /> FOR DEPARTMENT USE ONLY x l <br /> Application Accepts by Date V Area <br /> Pit or Grout Ins Inspection b 74 <br /> Date Final Inspection b Date 7 <br /> Additional Comments: I �. _ t, <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 /> INFO FEE AMOUNT DUE .n- AMOUNT REMITTED ASH RECEIVED 8Y DATE PERMIT NO. <br /> + EH 1241REV.FiNsr 4' 'g`,."� <br /> EH 14 <br /> -2a <br />