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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> '"RMIT 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 9��J lU Z_ City 4 Q 0 Lot Size aZA�- PM <br /> Owner's Name Lo b l 1412M+Ai Address , Phone <br /> c1 <br /> Contractor C c. Address f��tT bcj*/also —License No.3d �t Phone 3,61U F-U <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP'INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j <br /> D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing <br /> C7 Domestic/Private ElGravel Pack ❑ Tracy Type of Casing Specifications i <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout `ate <br /> Ll Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by ` <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> VVell Destruction ❑ Well Diameter ,„.,Sealing Material (top.50;) <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Z­DESTRUCTION ❑ (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 /> l Character of soil to a depth of 3 feet: A r"1 Water table depth j <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> k& TREATMENT PLT. ❑ Method of Disposal <br /> 4 <br /> . Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ;,' 9�—No. & Length of lines �1� y� Total length/size f <br /> FILTER BED D Distance to nearest: Well SOI Foundation Oen 1 Property Lina ff�.� <br /> SEEPAGE PITS N—Depth oZ � Size �ov Number <br /> SUMPS ❑ Distance to nearest: Well (9.1- —Foundation &N""""'"Propelty Line ID 1 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done,in accordance with Sart Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. ( Y ) I f <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 workmin's-compensation fawn of-Califomia."-'Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance.of fhe work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all re ired inspections. Complete dra;0ng on reverse side. f r <br /> Signed X Title: ctwf4 Date: <br /> I! FO�DEP RTMENT USE ONLY <br /> Application Acceptedby --4-�� L Date r- ,_ Area i <br /> it r Grout Inspection by ADate Gr `- Final Inspection by� / <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health'Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 , tslkil <br /> FEE <br /> INFO AMOUNT DUE _ AMOUNT REMITTED ASH RECEIVED BY DATE Q,(J�� PJERMIT'NO. <br /> + EH 1&24(REV.1/85) 70 o �, ;70O ( <br /> ^/ '0 xP �j <br /> EH 1426 <br />