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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA f <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 /4 900 IT 18JEE City d It' Lot Size 6A C PM <br /> Owners Name f—L2 Address M ® Phone "4 tV—1 f 3� <br /> Contractor 111 Address f sJL C R icense No.;UTgp(- P`hon,14's 24`D <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK !D SEWER LINES 150' ____ DISPOSAL FLD.'J'� PROP. LINE <br /> � <br /> FOUNDATION — AGRICULTURE WELL � OTHER WELL,?&b t PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j I <br /> ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ;(Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ;5TIr—a4 Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Zoo 1 /C, Type of Grouts 4wJ +CAFW45V <br /> ❑ Irrigation 7c/j22__hpprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 M <br /> TYPE OF SEPTIC WORK: ,.NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is O <br /> available within 200 feet.) Q ,f <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 ✓`1 `+ <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments \\v <br /> PKG. TREATMENT PLT. ❑ a Method of Disposal <br /> Distance to nearest: Well 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 <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. <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 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 must call for all req 'red inspecti s. Complete drawing on rey�jside. --�-- <br /> Signed Title: Ct2°\e !17R Gl D2 _ Date: <br /> IDEPARTMENT USE ONLY <br /> Q Q �" <br /> Application Accepted by Date_��1:4�T— Area � /�� <br /> Pit o Grout spection by Date �S Final inspection by l ­MM"a!`r Z Date LC�12 1 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMiT'NO. <br /> + EH 324{REV. /a5) <br /> 2 / �EH 1 0, , 0 J+ <br />