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APPLICATION FOR PERMIT iv <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T-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 xQ I fir GC A$-� �j al @ aS3S .�J <br /> City qLot Size PM <br /> Owner's Name ? 4c( Address s <br /> f Phone 16 X J r <br /> c-� <br /> Contractor h2e4 �r� $-/� Address ��. lf.S F"„f <br /> TYPE OF WELL/PUMP: icense No. �7Grout hone_ &. -.S <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCT <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OT <br /> SEWER LINES _ DISPOSAL FLD. LINE <br /> .FOUNDATION AGRICULTURE WELL <br /> OTHER WELL MPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Manteca❑ Domestic/Private ❑ Gravel Pack Dia. of Well Excavation Well <br /> Casing <br /> ❑ Tracy Type of Casing f i Public F1 Other Cl Delta nsDepth of Grout Seal —I 1 irrigation —_Approx. Depth �I ) Eastern utlk <br /> Repair Work Done L7 Type of Pump Surface Seal Installed by <br /> H.P. State Work Done_ <br /> Well Destruction ❑��Well Diameterll <br /> Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I REPAIR/ADDITION ! I DESTRUCTION 1No se tic-s stem <br /> P Y permitted if public sewer is <br /> Installation will serve: Residence— Commercial— Other �� available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/MfgWater table depth <br /> PKG. TREATMENT PLT. Cl Capacity— No. Compartments <br /> Distance to nearest: Well Method of Disposal <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED � Total length/size F <br /> ❑ Distance to nearest: Well t Foundation ' <br /> Property Line <br /> SEEPAGE PITS I I Depth Size <br /> SUMPS Number <br /> L� Distance to nearest: Well + <br /> DISPOSAL PONDS L1 Foundation Property Line <br /> 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 /> 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 issued;I shalt not( <br /> employ any person in such manner as to become subject to workman's compensation laws of California-" Contractors hiring or sub-contracting signature <br /> certifies.the following: "I certify that in the performance of the work for which this permit is issuedI shall em to <br /> tion laws of California." ,P p y persons subject to workman's compensa- <br /> 7he applica must call for II req ' inspections. Complete drawing on reverse side. <br /> Signed �,.rr <br /> Title: Q-4y(-e WC Yoe Dater s�l�" g ��►'� <br /> FOR.DEPARTMENT USE ONLY <br /> Application Accepted by r- <br /> c�"�l "a <br /> Pit or Grout Inspection b Date Area /J <br /> - <br /> ate Final Inspection by - �] <br /> Date <br /> Additional Comments: -]3-19 � <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71045 <br /> Applicant - Return all copies to:Environmental Health Permit/Services 1601 E.❑Haze ton Tracy 3Ave. 0. Box 2009 tk. A 9 1 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMITNO. <br /> + EH 13.241 Fill!/M5) © V <br />