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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 /> 1 (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. t <br /> �s+l f--� 11 ' <br /> Job Address _ � �.1°dL����RY Lot Size R d Jv PM <br /> (`1_ri Address Phone — <br /> mi <br /> .Owner's Nae �Ll -� • - { <br /> Contractor's Name License No. Phone <br /> =TYPE OF WELL/PUMP: NEW WELL a WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION)4 1 ' _ SYSTEM REPAIR E3 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES ' DISPOSAL FLD. PROP. LINE " C <br /> F FOUNDATION """ t, AGRICULTURE WELL OTHER WELL PITS/SUMPS cv�t1 <br /> 3 <br /> INTENDED, r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> 54ndustrial `Open Bottom, r--❑ Manteca• + --Dia. of Well Excavation Dia, of.Well Casing <br /> +GDo stic/Private ❑ Gravel Pack ❑ Tracy ., yp , gL� Specifications <br /> T e'of Casin <br /> I❑ Public ❑ Other L1 Delta `� Depth of Grout Seal _ Type f Grout <br /> 0 Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by' _ <br /> '`" I State Work Done <br /> ,Repair Work Done ❑ Type of Pump, <br /> � H.P.—� <br /> ,Well Destruction '� Well Diameter�l�Q Sealing Material (top 50'1 A <br /> 1 Depth ` a Filler Material (Below 501 <br /> k "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 /> " No. Compartments <br /> SEPTIC TANK El fly <br /> ` Ca Paci tY <br /> .PKG. TREATMENT PLT. 1-1Method of Disposal <br /> { Distance to nearest: Well Foundation Property Line <br /> ' I <br /> '[LEACHING LINE ❑ No. & Length of lines Total length/size <br /> 'FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> e +I <br /> 'SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 11ihereby 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 /> IHome 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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant st call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> r FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date 21 MS Final Inspection by Date <br /> i t � ✓ <br /> i,.,,,,,,,,.-Addi nal Comments:._-P-Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca, 823-7.104 a ;_❑ Tracy 8355-6385 <br /> 4 'Applicant- Return all copies to: Environmental Health PermitlSeivI eis 1601 E"Hazelton Ave., P.O. Box 2000, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE, PERMIT N0. <br /> INFO <br /> + EH 13-24(AEv.161831 19 O <br /> EH 14-28 <br />