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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> RECEIVED <br /> Telephone (209) 466-6781 AUG ? 198 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ENVIRONMENTAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wpRip 1giMf is applicatian is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and egulal4�ion f the San Joaquin <br /> Local Health District. l / <br /> 3139 City" "'° 7l"l.- Lot Size PM <br /> Job Address _ - <br /> Phone <br /> Owner's Name r <br /> y��, r Address ' <br /> f,� � [s'� 41& _Address License No Phone_ -//aContractor , - <br /> i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 11SYSTEM REPAIR 71 OTHER i <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 <br /> Dia. of Well Casing <br /> ElIndustrial ❑ Open Bottom LlManteca Dia. of Well Excavation <br /> �IDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications — <br /> f-1 Public Cl Other Cl Delta Depth of Grout Seal k Type of Grout �q <br /> I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done I Type of Pump— H.P. l State oL11I 4w. <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 — <br /> Depth Filler Material iBelow 50'1 -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1 1 DESTRUCTION { I No septic system permitted if public sewer is <br /> } available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> f Number of living units: Number of bedroomsa <br /> I "1 Water table depth <br /> Character of soil to a depth of 3 feet: f I <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PEE ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i FILTER BED ❑ Distance to nearest: Well Foundation ; y "' Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> i DISPOSAL PONDS ❑ <br /> I hereby certify that 1-have prepared this application and that the work will be done in accorda"aa with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health DFstrict. <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 ust call f It required inspections. Complete drawing on r arse silo. <br /> Signed X Title: Date: <br /> Ili <br /> FOR PARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Da Final Inspection by Dat/,4 " <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, 51k., CA 95291 <br /> k <br /> FEEAMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT IVO. <br /> GR <br /> INFO <br /> a EH 13-24(REV.t/n 5! <br /> Sr-/��7 <br /> EH 14-26 <br />