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J11APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA �^ ` <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p <br /> (Complete in Triplicate) '�- <br /> �/�/� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or in <br /> staN the work herein descnThis 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 RegAtions of the San Joaquin <br /> Local Health District: <br /> �{���,,,///111 `�' <br /> Job Address Z 79 7 /1 ��" � _ City / Lot Size PM <br /> Owner's Name �� AWA41nrs Address 4 Ira Phone 11757 <br /> Contractor1r Address �Z ! /Y4 License No. o29t��I3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 440 SEWER LINES DISPOSAL FLD,60 '�L 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 pia. of Well Casing <br /> Domestic/Private ,'�Gravel Pack f<Tracy Type of Casing pvG Specifications i <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal .5 Type of Groi^ 711f L <br /> ❑ Irrigation --Approx. 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 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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <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 /> 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 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 pentons subject to workman's compensa- <br /> tion laws of California." <br /> The applican st call for all,required i ti ns. Complete drawing on reve�side. <br /> Signed Title: Date: <br /> r DEPARTME T USE ONLY �( <br /> Application Accepted by Date�Y� Areao <br /> Pit or Grout Inspection by DateFinal Inspection by Date <br /> Additional Comments; � – rI_1_rA <br /> , <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 827104 ❑ 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 REMITTEDCCK n <br /> INFO RECEIVED BY DATE PERMIT NO. <br /> s EH 1241REV.1/851 { <br /> EH 14128 <br /> i i <br />