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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �TON AVE., STOCKTON, CA <br /> 1601 E. HAZE <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 J� Yi. �A) City Lot Size PM <br /> Owner's Name _ � � �S 0A-) Address Phone F <br /> Contractor JiCILG Address Chi �+f��TG�� License No. �s ._Phone Sc5�d5 <br /> TYPE WELOPUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> P INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEOTIC T SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION RICULTURE WELL OTHER WELL PITS/SUMPS } <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom El Manteca Dia. of We tion pia. of Well Casing <br /> 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ' Approx. Depth Cl Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump 1` H.P. State Work Done <br /> Well Destruction ❑ Well`Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION-0 (No septic'system permitted if public sewer is <br /> �` �" available within 200 feet.) <br /> Z.Installation will serve: Residence_k"/, Commercial— Other' <br /> Number of living units: l 111Number of.bedrooms <br /> Character,of soil to a depth of 3 feet: s, Water table depth <br /> SEPTIC TANK Type/Mfg � Z,j - Capacity 0-0 No. Compartments + # <br /> PKG. TREATMENT PLT. ❑ ', 4 a� '1 _ Method of Disposal I <br /> Distance to nearest: Welf 76"Foundation ` —6 Property Line <br /> LEACHING.LINE �' No. & Length of lines F3 1111--Total length/size 52ao ~ <br /> FILTER BED ❑ Distance to nearest: Well D��,Foundation Property Line <br /> SEEPAGE PITS""'-"'-'^'❑—'Depth''--""°"""- — —Size � / �'�Number <br /> SUMPS O Distance,to nearest:-- -;Weil�i _ Foundation `R� '"" !(dlJerty Cine <br /> DISPOSAL PONDS 171i. f Y. r�. i I f j <br /> hereby certify that 1.have prepared this application and that the workfwill be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations rtfie San,Joaquin Local Health District. r 3 <br /> Home owner or licensed-agent's signature certifies,the following;/"I certify that in the performance of the work for which this petmit is issued, I shall not <br /> employ any person in such manher as to become subiect to workman's.compensation-.laWs of California." Contractor's hiring or sub- contracting signature <br /> certifies,the-following:"I certify,that i)n'tho-performance of the4ork for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion iaws'of California::'..._.,,,„ -- <br /> The applica <br /> nt must call f all re ired i ctions. Complete drawing on reverse side. 4 7 <br /> Signed r Title: Date: �- <br /> !I <br /> 'F.OR DEPARTMENT USE ONLY 7 4 <br /> 1 I 'r � �d.� T <br /> Application'Accepteci by ! ! i ` Date Z " Area / <br /> , � k } �' t�l� <br /> Pit or Grout Inspection-bye �� j l`J TDate k Final Inspection by �".�:: Date_ i <br /> Aidditional Comments: <br /> ❑ Stk 466-6781' ❑ Lodi 369-3621 ❑ Manteca 823-7104 i ❑Tracy 835-6385 <br /> Applicant-!Raturn-ail-copies-to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r � f <br /> FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT''NO. w <br /> INFO <br /> r--•-+ EH13-21[REV:1/951 ­...,�.�.....;� <br /> EH 1428 <br />