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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 <br /> Local Health District. 1 1 <br /> Job Address J City t PM ' <br /> Owner's Name Address Phone <br /> f / /� S <br /> Contractor I R h 1�1'� Address 356 C icense No. d Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L-) Industrial ❑ Open-Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public i ' ❑ Other Cl Delta . Depth of Grout Seal Type of Grout_. <br /> I I Irrigation Yom. _._Approx. Depth l I Eastern Surface Seal Installed by - <br /> Repair,Work Done L]:,, Type of Pump H-Pr- State Work Done <br /> Well Destruction ❑r Well Diameter Sealing Material (top 501 '1 <br /> 1 r ` I -- <br /> _Depth..-.--- _l Filler Material (Below 50'1 <br /> l TYPE.OF,SEPTIC WORK: NEW INSTALLATION Ila REPAIRYADDITION [ RUCTION l I (No septic system permitted if public sewer is <br /> i t — available within 200 feet.) <br /> lnsfallation will serve: Residence� Commercial Other <br /> Number of living units: _L_ Number of bed oms� �- <br /> Character of soil to a depth of 3 feet:) PAL4� _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> 1 Distance to nearest: Well foundation Property Line <br /> LEACHING LINE 9--N—o'& Length of lines t length/size <br /> FILTER BED O Distance to nearest: Well Founda Property Line <br /> SEEPAGE PITS t I Depth I Size NVmber <br /> SUMPS L BiS`f nce to nearest: We114- - ­rFcpndatiorr`' `""rtProperty Line <br /> DISPOSAL,PONDS ❑ <br /> I hereby certify that I have prepared this applicationland 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-Di�tric#-..••-;� _---mss ^-^"^""''^^" -- <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 /> the following: " ce that in the performa of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws o lifarnia. /'1 <br /> 7 applican mu call ins ions. Co lete dra ing esici <br /> r r- <br /> j Date: <br /> Signe <br /> FOR DEPARTMENT USE ONLY ��77 <br /> ' !U <br /> Application Accepted by C Data Area <br /> li <br /> Pit or Grout Inspection by Date Final Inspection by Date - <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104, ❑ Tracy ..635-6385 <br /> k Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20 , Stk_, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT NO. <br /> INFO �'] <br /> +.EH1324iREV.r/n91 // }� _�l O �ia`(Q / <br /> EH 14-26 { 4y� <br />