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+' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 i <br /> Local Health District < <br /> Job Address y 6 City Lot Size .X3 Z Z PM rJ►✓ �� �` �' <br /> (� /J� /h/ �`� O <br /> Owner's Name ��ac�., V a� Address /. T.&I, /.3� Z 2L��/ Phone "`7216 <br /> Contractor . Address icense No. 99"/3 Phone <br /> TYPE OF WELL/PUMP: U NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK A00 SEWER LINES DISPOSAL FLD.1 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL •— PITS/SUMPS. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT_ION_P__ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> `Domestic/Private Gravel Pack Tracy Type of Casing Ve— Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 50 Type of Grou <br /> q' ❑ Irrigation ' ' ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done 13Type of Pump H.P. r State Work Done- <br /> Well <br /> one Well Destruction ❑ Well Diameter Sealing Material (top 501 F O <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTOUCTION ❑ (No septic system permitted if public sewer is { <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other _ 1 <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. 7 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <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-taws; and <br /> rules and regulations of the San Joaquin Local Health District. rt 1 <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 cert) that in the performance of the work for which this permit is issued,I shall em to t <br /> " certify pe p y persons subject to workman's compensa- o <br /> tion laws of California." <br /> The applicant oust call for all requi inspectiolls. Complet drawing on r verse side. <br /> SignedTitle: Date: <br /> 6-� -�'z <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date v� 6 Area 0 <br /> f <br /> Pit or Grout Inspection by Date v Final Inspection by Date f <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82.3-7104 ❑ Tracy 835-5385 I <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> EE <br /> FEE <br /> I <br /> INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24 IREV.1/e 5] ALJ <br /> EH 14-28 ,- d'� I �u <br />