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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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. <br /> �O/� 1 <br /> Job Address te -� C.f �. Cit y'y�_ Lot Size M <br /> Owner's Nam��4,1e Address Com"- Phone <br /> ` Cpntrac Address�U, ,? L' License N <br /> Phone-344-S-/0's" <br /> �T <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.-of Well Excavation Dia. of Well Casing <br /> Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ['1 Public ❑ Other M Delta Depth of Grout Seal Type of Grout <br /> ­ <br /> I I Irrigation —.-Approx. Depth I i Eastern Surface Seal Installed by I <br /> Repair Work-Done—ZI___Type of Pump H.P. State Work Done <br /> Well Destruction-, ❑ Well Diameter Sealing Material (top 50') -� <br /> y J Depth Filler Material (Below 50') <br /> � j <br /> TyPE`OF SEPTIC WORK: NEW INSTALLATION . REPAIR/ADDITION i I DESTRUCTION i I (No septic system permitted it public sewer is 1 <br /> t �4 1 available within 200 feet.) 0 y <br /> Installation4vill,serve: Residence Commercio'�/ OtherIL <br /> Number of living units 1, ' Number of bedrooms �! <br /> Character of soil.to a,depth-of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg T Capacit No. Compartments l <br /> PKG. TREATMENT PC ❑ "'"- Method of Disposal <br /> I f <br /> Distance_to.nearest:--- Well Foundation Property Line <br /> r � <br /> M LEACHING-LINE X-No. & Length of lines -, '° "'-""""`9 "'r""" —Total lengtFilsize x <br /> 01 r - <br /> FILTER BED t f Distance to nearest: Well 1.VAQ0 Found'afibn xProperty Line _ S' <br /> SEEPAGE PITS / Depth Size- s3 Number <br /> SUMPS Ll Distance to nearest: Well j(Z_ Foundation Property Line <br /> DISPOSAL PONOS 2,EI <br /> I 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 /> r^ rules and regulations of the San JoaquinLocal-Healih-Distric[.— <br /> ,,, _ - <br /> a Home owner or licensed agent's signature certifies the following: "I certify that in-thhe-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-law's of California." Contractor's hiring or sub-contracting signature <br /> certifies thb following: "I certify that in the performance of th_e.work-for-wFiich this permit is issued, I shall employ persons subject to workman's compensa- <br /> -'Ition law`s of California." "�� E ] <br /> /, �� <br /> The applicant SII for r uir d inspections. Complete,drawing an reverse sl <br /> t - c <br /> Signed X Title: Date:31 1 <br /> t ' FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date r� Area <br /> Pit or Grout Inspection by `i) t, Final Inspection by _ Date <br /> Additional Comments: - r <br /> ❑ Stk £466-6781! ___❑ Lodi.,369-3621 f '-D Manteca 623 7104 ❑ Tracy 835-6385 ; <br /> Applicarit'iFieturn all capias to: EnvironmentalHealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> CK 0 <br /> FEE <br /> INFO AMOUNT-qUE. I AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT'NO. <br /> +"EH 13-24(REV,tis 5f - <br /> Ek 14-28 <br />