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APPLICATION ` <br /> FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f <br /> 1601 E: HAZELON ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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. <br /> Job Address r IK-6-77C i"--/O <br /> City Lot Size / Z ly <br /> �� p <br /> Owner's Name OA�u IQ do;] iW - <br /> U,t/ Address /f�� / Cr'"M-41hone ` .7 <br /> Contractor Address`�' License No. Phone <br /> TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 6-6 ICT- SEWER LINES 3490 OCT <br /> DISPOSAL FLD. PROP. LINE �� <br /> FOUNDATION4AIACA-l"TAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE ..TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 9 Domestic/Private ❑fGravel Pack ❑ Tracy Type of Casing Specifications <br /> EJPublic EJOther ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation -!-Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump -rata H.P. State Work Done <br /> Well Destruction I] well <br /> iam ter y Sealing Material (top 50') CAI <br /> Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INS AT13PO REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septics stem <br /> I availablwithin 200 feet.) if public sewer is <br /> Installation will serve: Residence_.�. Commercial— Other <br /> Number of living units: Number of bedrooms <br /> r <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. ❑ t Method of Disposal <br /> Distance to nearest: Well r_ 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 f <br /> SUMPS ❑ Distance to nearest:? Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> ! 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. L x <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 Califomia."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of ttie work for which this permit is issued,I shall­-Contractor's <br /> subject to workman's compensa- <br /> tion laws of California." }' <br /> The applicant must ca I for all requ iro inspections. Complete drawing on rev se side. <br /> Signe Title: ZIV 4 �i �LD r p rp <br /> D FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ` Area <br /> Pit or Grout Inspection ate r Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8356385 <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 AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. <br /> + EH 13.24{REV,1/a 5) g� <br /> EH 14-28 L?b�� <br />