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APPLICATION FOR PERMIT _ - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT L� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> ` Telephone QW466_6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N`o <br /> (Complete in Triplicate) Imo , <br /> Application is hereby made to the San!Joaquin Local Health District for a permit to construct and/or instaherein described,ll the work <br /> of the San Joaquin This application is <br /> made compliance with San Joaquin County Ordinance No.549 for sewage or No1862 fll <br /> Local Health District. ��' -1 � . or we /pump and the Rules and Regulations <br /> � <br /> a <br /> Joh Address 3 1 <br /> City Lot Size PM <br /> Owner's Name �110hi 'dd <br /> - I <br /> Aress_ y 6 <br /> Phone LL➢➢ <br /> Contractor *' <br /> Address License No. <br /> TYPE OF W LL/PUMP: NEW WELL El --�_Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Q Industrial ❑ Open Bottom ❑ Manteca <br /> ❑ Domestic/Private 11 Gravel Pack El Tracy Type of Wel! Excavation Dia. of Well Casing <br /> ❑ Public Type of Casing Specifications <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation ---Approx. Depth ❑ EasternTYPe of Grout <br /> Repair Work Done ❑ T Surface Seal Installed by <br /> ype of H.P. State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Materia! [tap 501) <br /> Depth Filler Material )Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> Other Installation will serve: Residence Commercial_ vailable within 200 feet.) <br /> �4 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK X Water table depth <br /> Type/Mfg Capacity <br /> PKG. TREATMENT PLT. ❑ No. Compartments <br /> i k <br /> Distance to, nearest: Well Method of Disposal <br /> s I Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines <br /> FILTER BED ❑ DiTotal length/size <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> Number <br /> SUMPS <br /> ❑ Distance to nearest: Well Foundation " <br /> DISPOSAL PONDS Property Line_ <br /> { <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 <br /> employ any person g such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting rmit is issued, lsignalnot <br /> ture <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 usi call for all r _ fired inspections. Complete drawing on reverse side, <br /> Axl Signed <br /> Title. Date: 3 ` <br /> FOR DEPARTMENT USE ONLY _ <br /> Application Accepted by , <br /> Date — Area <br /> Pit or Grout Inspection by Date <br /> I Final inspection by Date <br /> Additional Comments f <br /> EJ Stk 456-6781 ❑ Lodi. 369 1 ` ❑ Manteca 823-7104 ❑ Tracy 835-6365 <br /> Applicant• Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE I AMOUNT REMITTED � <br /> pppyyy AS RECEIVED BY DATE PERMIT N0. <br /> + EH 13-24 MEV.t i e 5� C , s 9 U ` (c/, yn�J <br /> EH t426 r c�1 /� �d'/ <br />