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1 <br /> APPLICATION FOR PERMIT d <br /> SAN JOAQUIN�LOCAL--AEALTH 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) ry <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 bistrict.`°� <br /> . 'r ✓ / t Size PM <br /> Job Address �P" ��V z �© �� F City. _ � <br /> 'JI <br /> Owner's Name �AfG �� Address " Phone <br /> 1 <br /> Contractor Address 2-T A .fir C_YC)(/t a License Ho.3z�D*/b -PhoneZ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 4 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL I. OTHER WELL PITS/SUMPS 0 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA t CONSTRUCTION SPECIFICATIONS �,` <br /> L1Industrial ❑ Open Bottom LlManteca Dia. of Well Excavation Dia. of Well Casing I <br /> h <br /> ?+Domestic/Private ElGravel Pack ElTracy . Type of Casing Specifications <br /> ❑ Public ElOther ElDelta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth C1Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. _ State Work Done v <br /> Well Destruction ElWell Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LlREPAIR/ADDITION ❑ DESTRUCTION E] (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms iii ~ _ ' 4 1 <br /> Character of soil to a deptFi of 3 feet: "-- Water table depth <br /> SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT,PLT. ❑ [�. Method of Disposal <br /> r. <br /> Distance to nearest: - Well Foundation Property Line <br /> LEACHING LINEl ❑ No. & Length of lines Total length/size- - •-�--- <br /> r, <br /> FILTER BED : ❑ Distance to;nearest: Well - Foundation Property Line `• <br /> a _AJ 3' F <br /> SEEPAGE PITS f ❑ Depth t 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 accordan e-with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the-San Joaquin Local Health District.. 1 <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 h <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 app4an call for all required i pec ion Con pl drawing on verse side. <br /> d <br /> Signed X Title: l Date: �l <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by .Date Area <br /> Pit or Grout Inspection b t Date Final Inspection by Datef —/5_ <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 <br /> IFEE <br /> NFO AMOUNT:dUE AAOU>5 REMITTED GASH CK RECEIVED BY DATE PERMIT'NO. <br /> t <br /> + EH 13-241REV,1/851 <br /> EH 14-28 <br /> r <br />