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p APPLICATION FOR PERMIT <br /> -' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 /> Job Address � City 5L Lot Size PM <br /> Owner's Name 1 1SSA9,6_1 Address Phone <br /> ��AA��,,,. / t <br /> Contractor/r/L�iG/y/ IY.YGU Address fob f C�/L��i" License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION TEM REPAIR ❑ OTHER ❑ <br /> MOP <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINNES I DISPOSAL FLD. PROP. LINE <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 /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> j$Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump -� ' H.P. 7— State Work Done PULL._ y1d5 .EG77L� <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'} s" vL–/J�! SYY/�LL IVFl2� 1 <br /> Depth Filler Material (Below 501 12eAC' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is \]tel <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal ~ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property_,Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San-Joaquin county ordinances, state4not <br /> rules and regulations of the San Joaquin Local Health District. <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 issuedemploy any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contractincertifies 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 compns - <br /> tion laws of California." ! <br /> The applicant must Il for all required inspections. Complete drawing on reverse ide <br /> Signed X Title: Date: <br /> ✓��r� \� <br /> i�� G/L� fpm o� <br /> FOR DEPAR ENT USE ONLY <br /> Application Accepted by zlzx Date Area_ d <br /> V <br /> Pit or Grout Inspection by Date Final Inspection by Data <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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> + EH 13-24(REV.I/85) —7/ 1 "i 3 <br /> EH 14-2a a <br /> i <br />